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DISEASES 


OF 


THE    STOMACH 


A  TEXT-BOOK  FOR  PRACTITIO:NrERS 
ANJ)  STUDENTS. 


BY 

MAX  EIXHORX,  M.D. 


ADJUNCT  PROFESSOR  IN  CLINICAL  MEDICINE  AT  THE  NEW  YORK  POST-GRADUATE  MEDICAL 
SCHOOL   AND   HOSPITAL  ;    VISITING   PHYSICIAN   TO   THE   GERMAN   DISPENSARY. 


SeconD  IReviseD  JEMtion. 


NEW  YORK 

WILLIAM   WOOD   AND   COMPAITY 

1898 


Copyright  bv 

WILLIAM  WOOD   &   COMPANY 

1898. 


TO    MY    FRIEND    AND    TEACHER, 

C.  A.  EWALD,  M.D., 

PROFESSOR   OF   CLINICAL   MEDICINE   IN   THE    UNIVERSITY   OF   BERLIN 
THIS   BOOK    IS   RKSPECTFULLY    DEDICATED. 


PREFACE  TO  THE  SECOND  EDITION. 


It  is  about  a  year  now  since  my  book  on  "  Diseases 
of  the  Stomach"  was  pubHshed.  In  this  short  time 
the  first  edition  has  been  exhausted  and  a  reprint 
rendered  necessary.  It  is  quite  natural  that  in  so 
brief  a  period  no  radical  changes  were  called  for  in 
the  text.  A  revision,  however,  was  undertaken  and 
a  few  alterations  and  slight  additions  were  made. 

I  trust  that  the  second  edition  will  be  as  favorably 
received  by  the  medical  profession  as  the  first. 

Max  Ekshorn. 

New  York,  October  25th,  1897. 


PREFACE  TO  THE  FIRST  EDITION. 


During  the  last  twenty  years  our  views  in  the  field  of 
diseases  of  the  stomach  have  undergone  great  changes. 
W.  Beaumont  in  this  country  laid  the  corner-stone 
of  scientific  research  and  experimental  study  on  the 
functions  of  this  organ  in  1825.  From  that  time  on 
the  science  of  gastric  diseases  remained  in  a  state  of 
quiescence  until  1867,  when  Kussmaul  methodically 
applied  the  stomach  pump  in  the  treatment  of  dila- 
tation of  the  stomach.  The  real  progress,  however, 
began  a  few  years  later,  when  Leube  made  use  of  the 
stomach  pump  for  diagnostic  purposes.  Ewald,  Boas, 
Eeichmann,  Eiegel,  and  others  then  instituted  exten- 
sive studies  of  the  gastric  functions  in  health  and 
disease.  This  second  epoch  in  the  study  of  digestive 
diseases,  which  had  its  inception  in  Germany,  soon 
made  itself  felt  in  other  countries,  notably  France, 
Eussia,  Austria,  England,  and  America.  In  our  coun- 
try especially  it  seems  that  a  very  fruitful  activity  is 
developing  in  this  direction.  Among  the  older  writers 
I  would  mention  the  names  of  Austin  Flint,  Delafield, 
Pepper,  and  Osier,  all  of  whom  contributed  largely  to 
our  clinical  knowledge  in  this  branch  of  medicine. 
The  newer  researches  were  taken  up  here  and  further 
advanced   by  Charles  G.  Stockton,  Francis  P.  Kinni- 


Vlll  PREFACE. 

cut,  Allen  A.  Jones,  D.  D.  Stewart,  J.  C.  Hemmeter, 
and  many  other  very  active  investigators.  The  prog- 
ress achieved  relates  to  a  more  profound  knowledge 
of  gastric  affections — by  examination  of  the  functions 
— and  to  a  moro  successful  therapy,  first  by  diet, 
secondly  by  the  newer  mechanical  means  of  treatment 
(lavage,  sjDray,  electricity),  and  thirdly  by  surgical 
procedures.  Our  more  extensive  knowledge  of  diet 
and  treatment  is  of  advantage  not  only  to  the  specialist, 
but  to  the  general  practitioner  as  well,  and  it  is  with 
the  view  of  assisting  the  latter  in  the  acquisition  of 
all  these  advantages  which  have  of  late  accrued  that 
this  treatise  has  been  written.  A  series  of  articles 
on  Diseases  of  the  Stomach,  which  I  contributed  to 
the  "  Twentieth  Century  Practice  of  Medicine "  has 
greatly  facilitated  my  work.  In  this  book  the  subject 
has  been  considered  from  a  more  practical  standpoint, 
and  special  attention  has  been  paid  to  diet  and  treat- 
ment. I  trust  that  this  work  will  aid  in  awakening  a 
deeper  interest  in  the  study  of  diseases  of  the  stomach 
among  American  physicians,  and  if  this  object  be 
realized,  I  shall  feel  more  than  recompensed  for  the 
time  spent  in  its  preparation. 

Max  Einhorn. 

Nfav  York,  June  15th,  1896. 


CONTENTS. 


CHAPTER  I. 
Amatomy  axd  Physiology, 

PAGE 

Anatomy, 1 

Situation, 2 

Blood-vessels, 3 

Relations  of  the  Stomach  to  Neighboring  Organs,         .         .  3 

Structure  of  the  Stomach, 3 

Blood-vessels,  Lymphatics,  and  Nerves  of  the  Stomach,       .  7 

Physiology, 8 

The  Gastric  Juice, 10 

Gastric  Digestion, 13 

Intestinal  Digestion 14 


CHAPTER  II. 

Methods  of  Examination. 

Interrogation  of  the  Patient, 
Methods  of  Physical  Examination, 

Inspection, 

Palpation, 

Percussion, 

Auscultatory  Percussion, 
Sounds  of  the  Stomach, 

Splashing  Sound  (Clapotage) 

Deglutition  Sounds, 

Succussion  Sounds, 

Gurgling  Sounds, 

Respiratory  Sounds 

Sizzling  Sounds, 

Ringing  Sounds, 
Gastroscopy,    . 
Gastrodiaphany  or  Transillumination  of  the  Stomac 
Roentgen  Rays, 


18 
22 
22 
24 
26 
28 
29 
29 
30 
32 
32 
32 
33 
33 
33 
34 
38 


CONTENTS. 


Examination  of  the  Functions  of  the  Stomach, 
Secretory  Function,         .... 

Leube-Riegel's  Test  Dinner,     . 

Test  Breakfast  of  Ewald  and  Boas, 

Germain  See's  Test  Meal, 

Kleinperer's  Test  Meal,     . 

Ewald-Boas'  Expression  Method, 

Examination  of  the  Ingesta,     . 

Contraindications  to  the  Use  of  the  Stomach  Tube 

Otlier  Metliods  of  Testing  the  Gastric  Secretion 

Exact  Determination  of  the  Quantity  of  Chyme  w 
the  Stomach,       ...... 

Abnormal  Constituents  of  tlie  Gastric  Contents 
Absorptive  Function  of  the  Stomach,     . 
Motor  Function  of  the  Stomach,     .... 
Mechanical  Function,      ...... 


ithi 


PAGE 

,  39 
.  39 
,  40 
,  41 
.  41 
,  41 
.  43 
.  44 
.  60 
.  60 
1 

.  66 
.  68 
.  84 


CHAPTER  III. 
Diet. 

Animal  Foods, 

Vegetable  Foods,    . 

Liquid  Foods, 

Utilization  of  Food, 

Diet  in  Health, 

Diet  in  Diseases  of  the  Stomach, 

In  Acute  Diseases  of  the  Stomach, 
In  Chronic  Affections  of  the  Stomach, 


103 

105 
106 
107 
107 
108 
113 
116 


CHAPTER  IV. 

Local  Treatment  of  the  Stomach. 


Lavage, 

The  Gastric  Douche, 
The  Gastric  Spray, 
Electricity,     . 


126 
132 
134 
136 


CHAPTER  V. 

Organic  Diseases  with  Constant  Lesions. 

The  Acute  and  Chronic  Gastric  Catarrh 151 

Acute  Gastritis 151 

Gastritis  Acuta  Simplex  or  Acute  Gastric  Catarrh,        .         .151 
Etiology, ...   151 


CONTENTS.  XI 

PAGE 

Gastritis  Acuta  Simplex  or  Acute  Gastric  Catarrh  : 

Morbid  Anatomy, .  152 

Symptomatology, 153 

Diagnosis, 154 

Prognosis, 155 

Treatment, 155 

Gastritis  Phlegmonosa, 158 

Synonyms,          .         .         ,         .         .         .         .         .         .  158 

Morbi<l  Anatomy, 158 

Symptomatology, 158 

Diagnosis, 159 

Treatment,         .         .         . 159 

Gastritis  Toxica, 159 

Symptomatology, 160 

Diagnosis, 161 

Prognosis,          .........  161 

Treatment, 161 

Chronic  Gastric  Catarrh,  Gastritis  Glandularis  Chronica,     .  163 

Definition, 163 

Pathological  Anatomy, 163 

Etiology, .166 

Symptomatology, 167 

Course 173 

Diagnosis,          .........  173 

Differential  Diagnosis, 174 

Prognosis, 175 

Treatment, 175 


CHAPTER  VI. 

Organic  Diseases  with  Constant  Lesions — Continued. 

Ulcer  of  the  Stomach, =         .         .   187 

Synonyms, 187 

Definition, 187 

Etiology.  .         ,  187 

Morbid  Anatomy , 195 

Situation  of  the  Ulcer, .196 

Symptomatology, 203 

Duration  of  the  Disease, £12 

Complications, 213 

Diagnosis,         .......«.•  219 

Differential  Diagnosis,    .         .         .         .         .         .         •         •  220 

Localization  of  the  Ulcer, 222 

Prognosis, 223 


CONTENTS. 


Ulcer  of  the  Stomach  : 
Treatment, 

Diet  in  Gastric  Ulcer, 
Surgical  Procedures, 


.  234 
.  225 
.  233 


CHAPTER  VII. 
Organic  Diseases  with  Constant  Lesions— Continued. 

Erosions  of  the  Stomach, 238 

Definition 288 

General  Remarks ...  238 

Etiology, 239 

Symptomatology, 239 

Diagnosis, 245 

Treatment, 246 


CHAPTER   VIII. 

Organic  Diseases  with  Constant  Lesions — Continued. 

Cancer  of  the  Stomach  (Carcinoma  Ventriculi),  .         .         .  248 

Definition, 248 

Etiology, 248 

Parasitic  Theory, 254 

Morbid  Anatomy, 254 

Topographical  Relations 258 

The  Shape  of  the  Stomach, 259 

Secondary  Changes  Accompanying  Cancer  of  the  Stomach,  260 

Cancerous  Metastases 260 

Symptomatology 262 

Diagnosis, 277 

Differential  Diagnosis, 280 

Duration  and  Prognosis, 283 

Treatment 284 

Surgical 284 

Medical 287 

CHAPTER  IX. 

Functional  Diseases  with  Variable  Lesions. 


lerchlorhydria,         .... 

291 

Synonyms, 

291 

Definition,        ..... 

291 

General  Remarks,    .... 

291 

Etiology,           ..... 

293 

Symptomatology,    ._      . 

.  294 

CONTENTS.  xiii 

PAGE 

Hyperchlorhydria : 

Course, ...  296 

Prognosis, 298 

Diagnosis, 298 

Differential  Diagnosis, 299 

Treatment, 300 

Gastrosuccorrhoea  Continua  Periodica,         .        .        .        .        .  394 
Synonyms,       .         .         .        .         .         .         .         .         .         .394 

Definition, 304 

General  Remarks, 395 

Symptomatology, 3O5 

Diagnosis,        . 3IO 

Prognosis, 310 

Treatment, 310 

Gastrosuccorrhoea  Continua  Chronica, 312 

Synonyms 312 

Definition, 312 

General  Remarks, 312 

Etiology,  . 314 

Symptomatology, 314 

Diagnosis, .         .         .         ,  315 

Differential  Diagnosis, 316 

Prognosis, 321 

Treatment, 321 

CHAPTER  X. 
Functional  Diseases  with  Variable  Lesions— Continued. 

Achylia  Gastrica, 324 

Synonyms, 324 

Definition, 324 

General  Remarks, 324 

Morbid  Anatomy, 327 

Etiology, 328 

Symptomatology, .        .  328 

Course, 336 

Diagnosis, 336 

Prognosis, 337 

Treatment 337 

CHAPTER  XI. 
Functional  Diseases  with  Variable  Lesions — Continued. 

Ischochymia,  . 340 

Definition, 340 


xiv  CONTENTS. 

PAGE 

Ischochymia : 

General  Remarks,    ....  ...  340 

Symptomatology, 342 

Etiology, 845 

Course, 345 

Diagnosis, 360 

Treatment, 363 

Complications, 366 

Tetany, 366 

CHAPTER  XII. 

Abnormal  Conditions  with  Reference  to  the  Size,  Shape,  and 
Position  of  the  Stomach. 

Abnormalities  in  the  Size  of  the  Stomach, 373 

Abnormalities  in  the  Shape  of  the  Stomach,        ....  374 

Abnormalities  in  the  Position  of  the  Stomach,    ....  374 

Enteroptosis,  or  Glenard's  Disease 375 

Definition, 375 

General  Remarks, 375 

Etiology, 377 

Symptomatology, 379 

Diagnosis 381 

Treatment, 383 

CHAPTER  XIII. 
Nervous  Affections  of  the  Stomach. 

General  Remarks, 386 

Sensory  Gastric  Neuroses, 388 

(a)  Abnormal  Sensations  of  a  General  Character,         .         .  388 

Bulimia, 390 

Symptomatology, 390 

Treatment 391 

Parorexia  (Perversion  of  Appetite),         ....  392 

Polyphagia, 393 

Akoria, -         .  393 

Nervous  Anorexia ,         .  394 

Symptomatology 394 

Diagnosis, 396 

Treatment, 396 

(&)  Special  Sensations  within  the  Stomach  Itself,         .         .  398 

Gastric  Idiosyncrasies,     .......  399 

Abnormal  Sensations, 400 

Hyperaesthesia  of  tlie  Stomach, 401 


CONTENTS.  XV 

PA6K 

Hypersesthesia  of  the  Stomach : 

Symptomatology,        .  .  ...  402 

Diagnosis, 402 

Treatment,  .         .         .         .        .         .        .        .  403 

Gastralgia 404 

Synonyms, 404 

Symptomatology, 404 

Etiology, 406 

Diagnosis, 409 

Treatment, 413 

Motor  Neuroses, 414 

Spasm  of  the  Cardia  (Cardiospasmus),  ....  415 

Symptomatology, 415 

Diagnosis, 422 

Prognosis,  . 423 

Treatment, 423 

Eructation, 424 

Etiology, 425 

Treatment, 426 

Pyrosis, 426 

Eegurgitation, 427 

Etiology, 428 

Treatment, 428 

Rumination, 429 

Synonyms, 429 

Etiology, 429 

Duration, 43I 

Treatment, 436 

Nervous  Vomiting  (Vomitus  Nervosus),        ....   437 

Diagnosis, 439 

Juvenile  Vomiting,  .         .         .         .         .         .         ,   439 

Periodic  Vomiting, 440 

Reflex  Vomiting, 442 

Idiopathic  Nervous  Vomiting, 443 

Treatment, •.        .         .        .  443 

Pneumatosis,  ..........  444 

Hypanakinesis  Ventriculi ,        .  445 

Hyperanakinesis  Venti'iculi, 446 

Peristaltic  Restlessness  of  the  Stomach,  ....  446 

Treatment, 447 

Antiperistaltic  Restlessness  of  the  Stomach,  .         .        .  448 

Incontinentia  Pylori  (Incontinence  of  the  Pylorus),     .         .  449 

Pylorospasmus, 451 

Atony  of  the  Stomach, 453 


XVI 


CONTENTS. 


PAQE 

Atony  of  the  Stomach  : 

Synonyms,         ...  .  ...  453 

Symptomatology 453 

Diagnosis,  .........  453 

Prognosis, 454 

Treatment 454 

Secretory  Neuroses, 455 

Nervous  Dyspepsia, 457 

Etiology, 458 

Symptomatology 458 

Prognosis, 460 

Diagnosis, 461 

Differential  Diagnosis 461 

Treatment 462 


CHAPTER  XIV. 
The  Condition  of  the  Stomach  in  Diseases  of  Other 
Tuberculosis  of  the  Lungs, 
Chlorosis  and  Anaemia, 
Heart  Lesions, 
Disturbances  of  the  Liver, 
Diseases  of  the  Kidney, 
Diabetes, 

Arthritis  Deformans, 
Gout,       . 
Malaria, 
Diseases  of  the  Skin, 

Pemphigus  of  the  Mouth, 

Urticaria  and  Erythema, 

Eczema,  . 

Acne  Simplex  and  Acne  Rosacea, 


OF  Other  Organs. 

.  465 

.   468 

.  468 

.  469 

.  469 

.  470 

.  470 

.  470 

.  470 

.  471 

.  471 

.  472 

.  472 

.  473 

DISEASES  OF  THE   STOMACH. 


OHAPTEE   I. 

ANATOMY  AND   PHYSIOLOGY. 

Anatomy. 

The  stomach  is  a  pyriform  sac  the  longitudinal 
diameter  of  which  is  as  a  rule  oblique  in  position. 
The  larger  part  of  the  organ  is  situated  higher  up  and 
more  to  the  left  than  the  smaller,  which  is  directed  to 
the  right  somewhat  upward  and  sometimes  backward. 
This  smaller  extremity  terminates  in  the  small  intes- 
tine. The  point  at  which  the  stomach  communicates 
with  the  small  intestine  is  called  pylorus  (P)  and  is 
recognizable  on  its  outer  surface  by  a  furrow  and  on 
its  inner  surface  by  a  protruding  fold  (valvula  pylori). 
The  communication  between  the  oesophagus  and  the 
stomach  is  called  the  cardia  (C)  and  is  situated  at  the 
upper  part.  A  straight  line  (AB)  drawn  in  the  direc- 
tion of  the  oesophagus  and  prolonged  through  the 
stomach  would  cut  off  one-fourth  or  one-fifth  of  this 
organ  to  the  left.  This  portion  to  the  left  is  called 
the  greater  cul-de-sac  (saccus  csecus)  (F)  or  fundus. 
The  volume  of  the  stomach  varies  according  to  the 


2  DISEASES   OF   THE   STOMACH. 

condition  of  its  contents.  When  filled  its  long  diam- 
eter measures  20  to  31  cm.,  the  transverse  diameter 
being  8  to  10  cm.  at  the  fundus  and  much  less  at  the 
pylorus.     Here  it  measures  about  2.6  cm.     When  the 


FiQ.  1. — The  Stomach.    C,  cardia;  P,  pylorus;   F,  fundus;  G,  greater  curvature; 
L,  lesser  curvature. 

stomach  is  filled  the  anterior  wall  turns  somewhat 
upward  and  the  posterior  downward  (a  rotation  of 
the  organ  takes  place). 


Situation. 

The  stomach  lies  on  the  left  side  of  the  body,  and 
only  one-sixth  of  it  is  situated  on  the  right  side.  This 
includes  the  pylorus  and  the  adjacent  parts  which  lie 


STRUCTURE    OF    THE    STOMACH.  3 

behind  the  liver  (lobus  Spigelii).  The  cardia  is  situr 
ated  in  the  left  parasternal  line,  somewhat  above  the 
ensiform  process ;  the  lesser  curvature  lies  on  the  left 
side,  close  to  the  vertebral  column  and  runs  down- 
ward and  parallel  with  it.  The  greater  curvature 
extends  from  the  base  of  the  gall  bladder  and  the  liver 
into  the  left  hypochondriac  region  in  which  the  whole 
of  the  fundus  is  found. 

Blood-  Vessels. 

The  blood-vessels  enter  the  stomach  at  its  upper 
and  lower  borders  and  thus  divide  the  surface  of  the 
stomach  into  two  equal  parts.  These  lines  mark  the 
superior  and  inferior  margins  of  the  stomach,  the 
upper  and  lower  curvature,  or  the  lesser  and  greater 
curvature. 

The  Relations  of  the  Stomach  to  Neighboring 
Organs. 

The  left  segment  of  the  stomach  is  in  contact  with 
the  diaphragm  above,  and  to  the  left  with  the  spleen 
and  the  left  kidney.  The  lesser  curvature  and  the 
adjacent  part  of  the  organ  are  in  relation  with  the 
pancreas,  and  the  splenic  artery  and  vein.  The 
greater  curvature  and  a  portion  of  the  front  wall  as 
well  as  the  pylorus  touch  the  liver  and  also  the  trans- 
verse colon. 

Structure  of  the  Stomach. 

The  stomach  has  four  coats,  the  serous,  muscular, 
areolar  or  submucous,  and  mucous.  The  serous  coat 
is  derived   from   the  peritoneum  and   forms  a  thin, 


DISEASES   OF   THE   STOMACH. 


»' 


J!^^: 


smooth,  transparent  and  elastic  membrane.  It  closely 
covers  the  entire  viscus  excepting  along  its  two  curva- 
tures. Here  the  attachment  is  looser,  leaving  space 
for  the  larger  blood-vessels. 

The  muscular  coat  is  composed  of  plain  muscular 

tissue,  forming  three  sets  of  fibres  disposed  in  layers 

.^^  — namely,  the  longitu- 

^  :  j"  ■'  ■  :4       dinal,  the  circular,  and 

oblique  fibres.  The 
outermost  layer  is  the 
longitudinal  one,  then 
follows  the  circular, 
and  the  innermost  is 
the  oblique.  The  latter 
is  very  incomplete,  and 
is  a  continuation  of  the 
circular  fibres  of  the 
gullet.  These  fibres  de- 
scend obliquely  from 
the  cardiac  orifice  upon 
the  anterior  and  pos- 
terior surfaces  of  the 
stomach,  and  after 
spreading  out  from  one 
another,  they  run  in 
the  direction  of  the  cir- 
cular fibres  and  terminate  at  the  greater  curvature. 

The  submucous  coat  connects  the  muscular  and 
mucous  coats  and  consists  of  areolar  tissue.  It  is  the 
seat  of  division  and  passage  of  the  blood-vessels. 

The  mucous  membrane  is  a  smooth,  soft,  rather 
pulpy   membrane  which   has  a  somewhat  pink  hue. 


Fig.  5J.— a  Vertical  Section  of  the  Stomach. 
a.  Mucosa;  6,  submucosa;  c,  d,  muscu- 
laris;  e,  serosa.    X  60. 


STRUCTURE    OF    THE    STOMACH. 


It  is  thickest  in  the  pyloric  region  and  thinnest  at  the 
fundus. 

The  mucous  membrane  constitutes  the  glandular 
layer  of  the  organ.  The  glands,  which  number 
about  five  millions,  are  tubular  in  form  and  are  ar- 
ranged perpendicularly  to  the  surface;  at  their  base 
and  around  them  are  fibrous  tissue  and  lymphoid 
cells. 

The  glands  are  composed  of  the  following  parts: 
(1)  The  mouth;  (2)  the  neck, 
which    is    the    thinnest    part; 
(3)   the   body,    which    is  much 
thicker,  and  (4)  the  base. 

Several  tubules  (two  to  five) 
very  frequently  end  in  one 
mouth.  The  dots  that  are 
seen  on  the  surface  of  the 
mucosa  consist  of  the  open- 
ings of  the  glands.  The  whole 
inner  surface  of  the  stomach  is  " 
covered  by  columnar  epitheli- 
um, which  extends  for  a  vari- 
able distance  into  the  mouths 
of  the  glands. 

The  glands  are  divided  into 
two  kinds: 

1.  Cardiac  or  fundus  glands. 
These  fill  the  greater  part  of 
the  stomach  and  are  charac- 
terized by  the  two  following 
features:  The  mouth  of  the  gland  is  short  as  com- 
pared with  the   length    of    the    gland    itself.     They 


Fig.  3.— a  Cardiac  Gland,    a,  Pari- 
etal cells;  6,  principal  cells. 


6 


DISEASES   OF   THE   STOMACH. 


contain  parietal  or  oxyntic  cells,  which  are  closely 
arranged  in  the  neck  of  the  glands.  They  are  recog- 
nizable by  being  of  a  more  or  less  cuboid  shape  and 
having  a  dark  granular  appearance.  They  are  stained 
quite  deeply  with  the  aniline  dyes.  The  other  cells  of 
the  glands  are  called  the  princi- 
pal cells,  and  are  somewhat 
smaller  in  shape  and  not  so 
dark  as  the  parietal  cells. 

2.  The  pyloric  glands.  The 
mouth  of  the  gland  is  quite 
long  as  compared  with  the 
tube  itself.  The  body  of  the 
gland  consists  almost  entirely 
of  the  principal  cells.  No  jDari- 
etal  cells  are  to  be  found  here, 
although  some  cells  also  occur 
which  become  darkly  stained 
with  osmic  acid.  Nussbaum 
considered  them  similar  to  the 
parietal  cells  of  the  cardiac 
glands.  They  are  usually  called 
the  Nussbaum  cells. 

Besides  these  specific  glands 
there  are  a  number  of  mucous  glands  in  the  neigh- 
borhood  of  the  pylorus. 

Heidenhain,'    Kupffer,"   Sachs,'   and   Stoehr'   have 
greatly  contributed  to  our  knowledge  of  the  histology 

'  Heidenhain  :  Archiv  fiir  mikrosk.  Anat.,  vol.  6,  1870. 

2  Kupffer :  "Epithel  und    Driisen   des  menschlichen   Magens, " 
Miinchen,  1883. 

3  Sachs  :  Archiv  f.  experimeutelle  Patholog. ,  vols.  23  and  24. 
■•  Stoehr  :  Archiv  f.  mikrosk.  Anat.,  vol.  20. 


Fig.   4.— a    Pyloric    Gland,     o, 
Mouth;  6,  neck;  c,  fundus. 


VESSELS   AND   NERVES.  ? 

of  the  gastric  mucosa.  According  to  these  writers, 
the  principal  cells  generate  the  pepsin  and  the  rennet 
ferments,  whereas  the  parietal  or  oxyntic  cells  are 
imbued  with  the  faculty  of  secreting  hydrochloric 
acid. 

Blood-Vessels,  Lymphatics,  and  Nerves  of  the 
Stomach. 

The  arteries  of  the  stomach  originate  from  the  coe- 
liac  axis,  the  left  coronary  artery  being  a  direct 
branch  of  this  vessel,  and  the  right  a  branch  of  the 
hepatic  artery.  These  supply  the  smaller  curvature 
and  form  the  superior  ventricular  arch.  The  greater 
curvature  is  supplied  by  the  right  inferior  coronary 
artery,  being  a  branch  of  the  hepatic  artery,  and  by 
the  left  inferior  coronary  artery,  which  is  a  branch  of 
the  splenic  artery ;  they  both  form  the  inferior  ventric- 
ular arch.  All  these  vessels  reach  the  stomach  be- 
tween the  folds  of  the  peritoneum.  After  ramifying 
between  the  several  coats  and  supplying  them  with 
blood  (especially  giving  off  a  number  of  capillaries  to 
the  muscular  coat),  and  after  dividing  into  very  small 
vessels  in  the  submucous  areolar  tunic,  their  ultimate 
arterial  branches  enter  the  mucous  membrane  and 
ramifying  freely  pass  between  the  tubuli,  where  they 
form  a  plexus  of  fine  capillaries  upon  the  walls  of  the 
tubules  and  also  around  the  mouths  of  the  glands. 

The  veins  arise  from  the  capillar}'  network  and  pur- 
sue an  almost  straight  course  through  the  mucous 
membrane  between  the  glands.  After  piercing  the 
muscularis  mucosae  and  forming  a  wide  plexus  in  the 
submucous  tissue,  they  return  the  residual  blood  into 


8  DISEASES  OF   THE   STOMACH. 

the  splenic  and  superior  mesenteric  veins  and  also 
directly  into  the  portal  vein. 

The  lymphatics  of  the  gastric  mucosa  extend,  as 
first  shown  by  Loven,  directly  to  the  surface  of  the 
mucosa.  They  form  a  dense  network  of  lacunar 
spaces  situated  between  and  among  the  gland  tubuli, 
which,  as  well  as  the  blood-vessels  in  many  parts,  they 
enclose  with  sinus-like  dilatations.  IS^ear  the  surface 
of  the  membrane,  the  lymph  is  collected  into  vessels 
which  form  loops  or  possess  dilated  extremities. 
These  vessels  are  less  superficial  than  the  blood  capil- 
laries, although  the  lacunar  spaces  extend  as  far  as 
the  basement  membrane  of  the  surface. 

The  nerves  originate  from  the  abdominal  part  of 
the  vagus,  forming  the  interior  gastric  plexus  at  the 
cardia.  The  vagus  here  extends  over  the  whole  an- 
terior surface  of  the  fundus.  The  right  branch  of  the 
vagus  supplies  with  only  one-third  of  its  fibres  the 
stomach  wall,  especially  the  posterior  wall,  whereas 
two-thirds  supply  the  other  abdominal  organs.  The 
branches  of  the  sympathetic  nerve  coming  from  the 
coeliac  plexus  enter  into  many  ramifications  with  the 
vagus.  These  nerves,  wnth  a  number  of  small  gan- 
glia, form  a  network  in  the  submucosa. 

Physiology. 

The  stomach  forms  a  part  of  the  digestive  tract, 
and  in  order  to  understand  its  functions  thoroughly, 
it  will  be  best  to  give  a  short  review  of  the  entire  proc- 
ess of  digestion.  By  the  term  "digestion"  are  under- 
stood all  processes  which  serve  to  convert  the  various 


PHYSIOLOGY.  9 

food-stuffs  into  such  a  condition  that  they  become  fit 
for  entrance  into  the  circulation.  These  changes  are 
effected  by  means  of  ferments,  "which  replace  the 
Bunsen  flame  of  the  chemist  in  the  laboratory  of  the 
living  organism.  The  ferments  are  produced  by  liv- 
ing cells,  and  possess  certain  properties  in  the  way 
of  effecting  chemical  changes  when  in  contact  with 
certain  substances.  All  these  changes  can  ultimately 
be  explained  as  an  hydration  of  anhydrides — i.e., 
the  substances  developed  by  their  presence  contain 
more  water  than  the  primary  substances. 

All  ferments  possess  the  six  following  qualities: 

1.  They  are  of  organic  nature. 

2.  They  act  onl}^  in  the  presence  of  water. 

3.  The  total  amount  of  the  formed  products  con- 
tains more  hydrogen  and  oxygen  (in  the  relation  of 
water)  than  the  original  substance. 

4.  They  decompose  peroxide  of  hydrogen. 

5.  They  act  best  at  temperatures  varying  between 
30°  and  60°  C. 

6.  Each  ferment  possesses  a  specific  action,  and  one 
and  the  same  substance  may  develop  different  prod- 
ucts when  in  contact  with  different  ferments. 

The  ferments  are  divided  into  two  classes: 

1.  Formed  ferments:  those  whose  active  princi- 
ple cannot  be  separated  from  the  original  cell  in  which 
they  are  generated  and  is  dependent  on  the  life  of 
their  mother  substance  (yeast  cells). 

2.  Unformed  ferments:  those  which  can  be  sepa- 
rated from  their  original  soil  without  losing  their  sjdc- 
cific  action. 

Most  of  the  ferments  that  exist  in  the  living  organ- 


10  DISEASES  OF  THE   STOMACH. 

ism  are  uDformed  (ptyaliii,  pepsin,  rennet,  tryp- 
sin, etc.). 

Thus  far  all  attempts  to  isolate  ferments  in  a  chem- 
ically pure  state  have  been  unsuccessful.  We  only 
know  that  they  are  organic  hodies  whose  structure  is 
similar  to  that  of  the  proteids. 

In  the  mouth  the  food  first  comes  in  contact  with 
the  saliva  by  the  act  of  chewing.  This  secretion  con- 
sists of  the  products  of  the  salivary  and  mucous 
glands  of  the  mouth.  It  is  of  alkaline  reaction,  low 
specific  gravity  (1.002-1.009),  contains  epithelia,  mu- 
cus, ptyalin,  albumin,  and  some  salts.  It  also  con- 
tains traces  of  potassium  rhodanate  (CNKS).  After 
being  lubricated  by  the  saliva,  the  food  passes  through 
the  pharynx  and  oesophagus  into  the  stomach.  The 
ptyalin,  which  is  characterized  by  converting  starch 
into  maltose  or  sugar,  begins  its  action  upon  the  food 
already  in  the  mouth,  but  the  principal  work  is  done 
during  the  first  period  of  digestion  within  the  stom- 
ach. 

The  Gastric  Juice. 

Spallanzani '  and  Reaumur  were  the  first  to  make 
experimental  studies  upon  the  gastric  juice.  They 
recognized  its  property  of  digesting  meat  and  of  ex- 
erting an  antifermentative  action.  Prout  in  ISiJi 
discovered  hydrochloric  acid  in  the  gastric  juice. 
These  experiments  have  been  greatly  furthered  and 
advanced  in  this  country  by  Beaumont,*  who  at  about 

'  Spallanzani .  "  Versuche  iiber  das  Verdauungsgeschaf t, "  Ab- 
handlung  vi. 

2  Beaumont :  "Experiments  and  Observations  of  the  Gastric 
Juice  and  the  Physiology  of  Digestion,"  Combe's  edition,  1833. 


THE    GASTRIC   JUICE.  11 

the  same  time  made  a  series  of  investigations  upon 
the  well-known  Canadian  St.  Martin  with  his  gastric 
fistula.  Many  of  the  facts  discovered  by  Beaumont 
form  the  basis  of  our  knowledge  of  the  physiology  of 
the  stomach ;  as.  for  instance,  his  observations  on 
the  movements  of  the  stomach.  Blondlot  *  first  estab- 
lished a  gastric  fistula  in  animals  for  experimental 
purposes.  Bidder  and  Schmidt  ^  have  conclusively 
shown  that  the  acid  of  the  gastric  juice  is  hydro- 
chloric acid,  while  Schwann  in  1836  discovered  the 
pepsin  ferment.  The  nature  of  the  acid  of  the  gastric 
juice  has  been  the  subject  of  much  controversy  even 
during  late  years.  Thus  Winter  and  Hayem'  dis- 
puted the  formation  of  hydrochloric  acid  within  the 
gastric  glands.  They  assert  that  while  the  glands 
produce  an  organic  acid,  this  is  changed  into  an  in- 
organic by  the  presence  of  salt  (sodium  chloride) 
within  the  stomach.  This  theory,  however,  is  incor- 
rect, as  it  is  well  known  that  the  stomach  will  furnish 
a  secretion  containing  free  hydrochloric  acid  even 
when  no  food  or  other  substance  containing  sodium 
chloride  has  been  ingested. 

The  gastric  juice  is  a  clear,  colorless  fluid  of  an  acid. 
reaction  and  a  specific  gravity  of  1.(j(j-2-1.(j0o.  The 
quantity  secreted  in  twenty -four  hours  is  not  exactly 
known.  It  is  estimated  by  some  to  be  about  three 
pints.  The  principal  constitutents  of  the  gastric  juice 
are :     (1)  Hydrochloric  acid  :    {2')  pepsin  ;  (3)  rennet. 

The  degree  of    acidity  varies  from  0.1  to  0.:2  per 

^  Blondlot :  •■  Traite  aualvtique  de  la  digestion,  "  Paris,  1843. 

2  Schmidt :  Liebig's  Annalen.  xcii..  1854. 

^  Winter  and  Havem  :  "Du  Chimisme  Stomachale/"  Paris,  1891. 


12  DISEASES  OF  THE   STOMACH. 

cent.  Both  fermeuts,  pepsin  and  rennet,  when  first 
secreted  are  inactive  hodies  and  called  respectively 
pepsinogen  and  rennet-zymogen,  but  coming  in  con- 
tact with  the  acid  become  converted  into  active  pepsin 
and  rennet.  Besides  these  three  substances,  the  gas- 
tric juice  contains  water,  inorganic  salts,  and  some 
proteid  matters. 

The  greatest  difiQculty  in  explaining  the  production 
of  gastric  juice  was  encountered  in  the  circumstance 
that  an  inorganic  acid  should  be  secreted  by  the  blood, 
which  is  a  strongly  alkaline  solution.  Maly,'  how- 
ever, gave  the  following  explanation :  Some  liquids 
with  alkaline  reaction  may  contain  acid  salts;  thus  in 
the  blood  there  exist  disodic  orthophosphate  and 
monosodic  orthophosphate  (Xa^HPO^  and  TsaH„POJ, 
together  with  distinctly  alkaline  salts.  When  such  a 
solution  is  placed  into  a  dialyzer  immersed  in  distilled 
water  the  acid  principle  passes  into  the  latter.  Thus 
within  the  dialyzer  there  is  an  alkaline  and  outside  an 
acid  liquid.  Maly  compares  the  stomach  and  the 
kidneys  to  a  dialyzer,  and  explains  in  this  way  the 
secretion  of  acid  fluids  from  the  kidneys  and  from  the 
.stomach.  The  details  of  the  formation  of  hydrochlo- 
ric acid  may  be  given  as  follows:  If  Na„HP04  is 
brought  together  with  calcium  chloride  (CaClJ,  there 
is  formed  triphosphate  of  calcium,  sodium  chloride, 
and  free  hydrochloric  acid  according  to  the  follow- 
ing formula:  2Na,HP0,  +  3CaCL  =  Ca3(P0J,  + 
4NaCl  +  2HC1. 

This  theory,  although  very  ingenious,  does  not  suffice 

'  Maly:  "  Untersuchungen  liber  die  Mittel  zur  Saurebildung  im 
Organismus. "     Zeitschrift  fiir  i^hysiologische  Chemie,  i.,  p.  174. 


GASTRIC    DIGESTIOX.  13 

to  explain  the  entire  process  of  gastric  secretion.  For 
there  is  no  reason  why  the  hydrochloric  acid  should 
not  be  secreted  in  other  organs  than  the  stomach,  the 
blood  coming  into  contact  with  many  other  glandular 
apparatuses.  Besides,  this  theory  does  not  explain 
why  the  secretion  should  not  go  on  all  the  time  in 
the  stomach.  Here  as  elsewhere  we  are  forced  to 
accept  a  specific  action  of  the  cells  which  cannot  be  ex- 
plained by  simply  physical  or  chemical  laws.  We 
know  that  there  are  cells  imbued  with  certain  specific 
actions  that  are  unexplainable  by  chemical  formulaB. 

Gastric  Digestion. 

The  principal  part  played  by  gastric  digestion  con- 
sists in  the  conversion  of  albuminates  into  the  more 
soluble  forms  of  propeptones  and  peptones,  which  are 
the  result  of  the  combined  action  of  hydrochloric  acid 
and  pepsin.  The  rennet  ferment  curdles  milk.  The 
gastric  juice  is  also  endowed  with  the  property  of  con- 
verting cane  sugar  into  grape  sugar,  and  gelatin  into 
a  soluble  form  (a  peptone)  which  no  longer  coagu- 
lates. Besides  this,  a  small  percentage  of  fat  is  split 
into  fatty  acids. 

The  work  accomplished  by  the  stomach  in  the  act 
of  digestion  must  also  be  ascribed  to  the  active  and 
passive  movements  that  take  place  in  this  organ,  in 
consequence  of  which  certain  physical  changes  are 
effected  in  the  ingested  food.  Each  particle  of  food 
is  brought  into  more  intimate  contact  with  the  stom- 
ach walls  by  these  movements  than  would  otherwise 
be  possible.  The  food  as  a  whole  becomes  more  lique- 
fied and  passes,  as  chyme,  through  the  pylorus  into 


14  DISEASES    OF    THE    STOMACH. 

the  small  intestines.  The  pylorus  is  said  to  control 
the  entrance  of  the  more  liquid  chyme  into  the  duo- 
denum. It  opens  and  closes  at  certain  intervals.  We 
are  as  yet  not  able  to  give  a  full  explanation  for  this 
seemingly  elective  action  of  the  pylorus,  nor  do  we 
exactly  know  at  what  intervals  the  pylorus  opens.  It 
is  only  known  that  at  certain  times  after  certain 
meals  (about  two  hours  after  a  small  meal,  six  to 
seven  hours  after  a  large  meal)  the  stomach  is  com- 
pletely empty. 

Some  of  the  substances  contained  in  liquefied  chyme 
are  absorbed  through  the  stomach  wall,  such  as 
sugar,  salts,  peptone,  perhaps  propeptones;  the  rest 
passes  into  the  small  intestine,  and  is  subjected  to  the 
action  of  several  secretions  that  combine  there  in  order 
to  further  change  it  and  make  it  fit  for  absorption. 

Intestinal  Digestion. 

Although  it  is  not  my  intention  to  give  a  detailed 
description  of  the  process  of  intestinal  digestion,  it 
might  still  be  useful  briefly  to  discuss  the  further  fate 
of  the  chyme.  On  the  entrance  of  the  chyme  into  the 
duodenum,  it  is  subjected  to  the  influence  of  the  bile 
and  pancreatic  juice,  which  are  there  poured  out  and 
also  to  that  of  the  intestinal  secretion.  All  these 
secretions  have  a  more  or  less  alkaline  reaction,  and 
through  their  admixture  with  the  chyme  its  acidity 
becomes  less  and  less,  until  at  length,  at  about  the 
middle  of  the  small  intestines,  the  reaction  becomes  al- 
kaline and  continues  so  as  far  as  the  ileo-csecal  valve. 

Of  the  bile  we  know  that  it  has  a  strongly  alkaline 
reaction  and  that  it  is  able  to  emulsify  fats.     It  also 


INTESTINAL  DIGESTION.  15 

possesses  antifermentative  and  slightly  purgative  prop-, 
erties. 

The  importance  of  the  liver,  however,  cannot  be 
judged  from  the  influence  which  the  bile  exerts  upon 
the  digestive  economy.  "  To  regard  the  liver  in  this 
light,"  says  L.  Brunton,'  "is  just  about  as  rational  as 
to  think  that  an  Atlantic  steamer  has  been  built  for 
the  express  purpose  of  throwing  out  from  its  sides  the 
two  jets  which  are  formed  by  the  waste  water  from  the 
engines.  The  condensed  steam  may  be  utilized  and  so 
may  the  bile,  but  the  condensation  of  steam  is  not  the 
main  object  of  an  Atlantic  steamer,  nor  is  the  secretion 
of  bile  a  chief  function  of  the  liver." 

All  the  blood  from  the  stomach  and  intestines  must 
pass  through  the  portal  vein  before  it  can  reach  the 
general  circulation.  The  hepatic  tissue  acts  the  part 
of  a  prudent  porter  at  a  gate,  and  turns  back  or  de- 
stroys dangerous  intruders.  The  liver  serves,  briefly, 
the  four  following  purposes : 

1.  It  is  a  kind  of  store-room  of  the  organism,  many 
substances  taken  up  by  the  digestive  process  being 
kept  there  until  their  final  use  in  the  system.  Thus 
many  of  the  peptones  and  the  greatest  part  of  sugar 
are  stored  up  in  the  liver  as  glycogen. 

2.  It  excludes  from  the  circulation  several  poisonous 
matters  or  destroys  them;  curare,  for  instance,  which 
is  so  poisonous  when  injected  into  the  blood,  proves 
quite  innocuous  when  taken  by  the  mouth,  the  reason 
being  that  the  liver  does  not  pass  this  poisonous  matter 
into  the  circulation  but  retains  it,  and  finally  ex- 
cretes it   through    the   bile.     The   liver   guards    the 

*  T.  L.  Brunton  :  "  Disorders  of  Digestion, "  London,  1893. 


16  DISEASES   OF   THE   STOMACH. 

organism  from  the  entrance  of  many  detrimental  sub- 
stances. 

3.  It  has  also  been  proven  lately  that  the  liver  is  the 
main  place  where  urea  is  formed. 

4.  The  secretion  of  bile. 

If  now  we  return  to  the  subject  of  intestinal  diges- 
tion, w^e  shall  have  to  speak,  firstly,  of  the  pancreatic 
secretion,  which  is  the  most  energetic  and  general  in 
its  action  of  all  the  digestive  juices.  It  unites  in  itself 
the  action  of  the  saliva  and  the  gastric  juice  besides 
having  properties  of  its  own.  By  means  of  its  tryjDsin 
ferment,  it  converts  albuminous  bodies  into  peptones, 
but  in  a  much  shorter  time  than  the  gastric  juice.  If 
the  action  of  the  pancreatic  juice  upon  albumin  goes 
on  for  a  longer  period  of  time,  then  leucin,  tyrosin, 
and  several  other  derivatives,  as  asparaginic  acid  and 
hypoxanthin'  are  formed.  Its  diastatic  ferment  con- 
verts starch  into  sugar  and  acts  in  the  same  way  as 
ptyalin,  only  more  intensely.  The  third  ferment  it 
contains  is  steapsin,  which  emulsifies  fats  and  tends 
to  split  them  up  into  fatty  acids  and  glycerin.  The 
chemical  formula  for  this  process  may  be  expressed  as 
follows : 

Tristearin        Steapsin    _.     Water    _  Glycerin    _.       Stearinic  acid 


,     Water    _  Glycerin     ,       Stearinic 

"*"       SHOa       "'C3H5(OH3)"^C,tH35— CO 


CsHsCCHsi— COOH)3     '      SHOa        C3H5(OH3)  '  C,tH35— COOH)^ 

The  pancreatic  juice  acts  in  an  alkaline  medium,  and 
the  chyme  after  its  entrance  into  the  small  intestine  is 
rendered  alkaline  by  the  conjoint  action  of  the  bile, 
the  pancreatic  juice  itself,  and  the  enteric  juice.  The 
latter,   the  juice  secreted  by  the  small  intestines,  is 

'See  C.  A.  Ewald  :  "Die  Lebre  von  der  Verdauung, "  p.  176, 
Berlin,  1890. 


INTESTINAL    DIGESTION,  17 

knownJ;o_dissoh'e_onlj  fibrin,  but  it  is  yet  uncertain 
whether  it  contains  a  diastatic  ferment. 

The  substances  that  have  been  left  undigested  in  the 
stomach  are  quickly  changed  into  soluble  products  in 
the  small  intestines  (chyle)  and  taken  up  by  the  lym- 
phatics and  the  venous  blood  current.  The  principal, 
part  of  absorption  is  performed  in  the  small  intestines. 
The  chyle  has  a  slightly  alkaline  reaction  until  it  en- 
ters the  large  intestines,  where  it  again  is  rendered  acid 
by  some  of  the  products  of  decomposition  generated  in 
the  lower  part  of  the  small  intestines.  In  their  pas- 
sage along  the  large  intestine  the  undigested  materials 
assume  a  more  solid  consistence  in  consequence  of  the 
absorption  of  the  fluid  jDortion,  and  become  gradually 
changed  into  fseces  and  are  expelled  by  the  rectum. 
Several  products  of  proteid  decomposition  are  formed 
in  the  large  bowels.  One  of  these,  discovered  by 
Brieger,'  is  called  skatol  (CgHgX),  to  which  the  offensive 
smell  of  the  faeces  is  principally  due. 

'  Brieger  :  "Ueber  die  fluchtigen  Bestandtheiledermenschlichen 
Excremente. "    Journal  fiir  prakt.  Chemie,  1877. 
2 


CHAPTEE  II. 

METHODS   OF   EXAMINATION. 

The   Interrogation   of   the    Patient. 

The  examination  of  the  patient  begins  with  the  nar- 
ration of  the  course  and  symptoms  of  his  trouble  past 
and  present.  The  history  must  state  how  long  the 
trouble  has  existed,  whether  it  began  gradually  or 
suddenly;  and  the  supposed  cause  of  the  ailment. 
We  have  to  inquire  whether  the  disease  has  constant- 
ly progressed  or  whether  it  has  been  interrupted  by 
free  intermissions.  We  have  further  to  inquire 
whether  the  symptoms  have  always  been  the  same  or 
whether  they  have  changed  in  character  since  the 
beginning  of  the  trouble.  It  is  important  to  know 
whether  there  has  been  loss  of  flesh  and  whether  this 
has  been  continually  increasing.  We  should  inquire 
also  as  to  the  condition  of  the  bowels,  whether  there 
is  constipation  or  diarrhoea  or  both  interchangeably. 

Present  condition :  The  patient  should  be  requested 
to  describe  the  symptoms  he  complains  of.  As  this, 
however,  is  not  done  very  accurately  by  the  patient 
himself,  we  shall  find  it  frequently  necessar}^  to  cross- 
examine  him.  The  important  points  to  which  atten- 
tion should  be  directed  in  our  cross-examination  are  as 
follows : 


THE  INTERROGATION  OF  THE  PATIENT.       19 

The  A2:>petite. — Is  there  loss  of  appetite  ?  Does  the  ap- 
petite come  when  the  patient  begins  to  eat?  Does  the 
appetite  disappear  when  tiie  patient  has  taken  a  few 
mouthfuls  of  food,  or  is  there  a  ijerfect  aversion  for 
food?  The  loss  of  appetite  is  designated  by  the  word 
"anorexia."  If  there  is  a  perversion  of  appetite — that 
is,  appetite  only  for  unusual  substances — 'We  speak  of 
"parorexia."  If  the  appetite  is  increased — that  is,  if 
the  patient  becomes  hungry  soon  after  a  meal — we 
speak  of  "bulimia."  If  the  patient  takes  large  quan- 
tities of  food,  much  more  than  normal,  but  at  his 
regular  meals,  we  speak  of  "polyphagia."  If  there  is 
no  feeling  of  satiety  no  matter  how  much  the  patient 
takes,  then  we  sjDeak  of  "acoria." 

Thirst.  —  Inquire  whether  the  patient  becomes 
thirsty  more  frequently  than  usual  or  whether  there 
is  no  desire  whatever  for  drinks. 

Taste. — Inquire  whether  the  taste  in  the  mouth  is 
all  right  or  whether  it  is  bitter,  sour,  or  sticky,  and  if 
there  is  such  abnormal  taste,  at  what  time  it  is  mostly 
experienced. 

Deglutition. — Does  the  food  pass  into  the  stomach 
without  difficulty  or  not?  If  not,  state  whether  the 
difficulty  is  experienced  only  after  ingestion  of  solid 
substances  or  also  after  fluids. 

Abnormal  Sensations. — How  do  you  feel  after 
meals?  Do  you  feel  bloated?  Do  you  experience  a 
feeling  of  fulness  or  pressure  in  your  gastric  region? 
Do  you  feel  sleepy  or  giddy,  and  if  so  for  how  long  a 
time? 

Belching. — Do  you  belch  much  and  if  so,  when? 
Does  it  occur  only  after  a  meal  or  also  in  the  morning 


20  DISEASES    OF   THE   STOMACH 

when  the  stomach  is  emiDty?  Do  you  belch  so  much 
that  it  inconveniences  you  in  society,  or  that  it  keeps 
you  from  your  business?  Is  the  belching  connected 
with  some  bad  smell,  or  is  the  gas  that  comes  up  odor- 
less, inoffensive? 

Regurgitation. — Does  the  food  come  up  into  your 
mouth?  If  so,  state  whether  it  is  sour  or  not,  and 
whether  this  frequently  occurs  and  how  long  after 
meals.  If  the  food  that  comes  up  is  spit  out  we  speak 
of  "regurgitation,"  but  if  it  is  chewed  and  swallowed 
we  speak  of  "rumination,"  If  only  some  sour  fluid 
comes  up,  then  we  speak  of  "water  brash." 

Pyrosis. — Do  you  experience  a  burning  sensation 
at  the  j)it  of  your  stomach,  and  when?  Is  it  half 
an  hour  after  a  meal,  or  is  it  three  hours  or  so 
afterward?     How  long  does  this  sensation  last? 

Pains. — Pains  when  experienced  at  the  pit  of  the 
stomach  are  called  cardialgia;  if  in  the  gastric  region, 
gastralgia.  Pains  are  the  most  frequent  complaints 
met  with  in  all  kinds  of  digestive  troubles.  They  may 
be  of  a  severe  nature  so  that  the  patient  is  obliged  to 
stay  in  bed,  or  they  may  be  of  only  a  light  character 
so  as  merely  to  inconvenience  the  sufferer.  When  does 
the  pain  appear?  Does  it  come  right  after  eating  or 
does  it  occur  an  hour  or  two  or  three  afterward? 
Does  it  exist  when  the  stomach  is  empty  and  is  it  ap- 
peased by  the  ingestion  of  food?  How  long  does  the 
pain  last?  Does  it  remain  all  the  time,  or  only  a 
short  while,  or  does  it  come  and  go  independently 
of  the  food  taken?  If  it  follows  the  ingestion  of  food, 
is  it  more  intense  after  partaking  of  certain  coarse,  in- 
digestible aliments?     Is  the  pain  circumscribed  and 


THE    INTERROGATION    OF    THE    PATIENT.  21 

felt  ODly  at  one  spot  or  does  it  extend  all  over  the  gas- 
tric region?  Does  it  radiate  to  the  back  and  shoulder 
blades?  Does  the  pain  come  on  suddenly  or  slowly, 
and  does  it  gradually  increase? 

Nausea. — Is  the  nauseous  feeling  present  only  in  the 
morning  or  after  each  meal,  or  does  it  appear  after 
certain  foods  (as  meats)? 

Fo7?^^7mgr.— Inquire  whether  the  patient  vomits ;  if 
so,  how  often  this  occurs,  whether  daily  or  only  once 
in  two  or  three  weeks.  Does  the  vomiting  occur  soon 
after  a  meal  or  at  other  times?  Does  it  occur  in  the 
middle  of  the  night?  Do  you  vomit  large  quantities? 
If  so,  of  what  do  they  consist?  Is  it  only  food  or  is 
it  simply  an  acid  watery  fluid?  Does  the  vomited 
matter  contain  food  from  previous  days?  Does  it  con- 
tain much  bile?  Does  it  smell  when  it  is  vomited  or 
has  it  an  acid,  disagreeable  taste?  Was  there  ever 
any  blood  in  it?  Fresh  blood  looks  red,  while  digested 
blood  that  has  been  in  the  stomach  a  much  longer 
time  has  a  coffee-brown  color.  Is  the  act  of  vomiting 
connected  with  much  exertion  or  does  it  take  place 
easily?  Do  pains  exist  before  vomiting  and  disajDpear 
after  its  cessation? 

Boiuels. — Inquire  whether  the  bowels  move  every 
day  or  not.  Are  they  constipated?  Is  the  patient 
always  obliged  to  take  some  aperient  and  what  is  the 
nature  of  the  aperient?  Is  there  diarrhoea?  State 
how  many  movements  a  day  and  the  character  of  the 
stools,  whether  they  are  very  watery  or  whether  there 
is  some  admixture  of  mucus  or  blood.  Does  the  diar- 
rhoea appear  after  each  meal?  Does  it  alternate  with 
periods  of  constipation? 


22  diseases  of  the  stomach. 

Methods  of  Physical  Exai^iination. 

The  examination  of  the  patient  should  always  begin 
with  a  thorough  examination  of  his  chest,  for  very 
often  persons  complaining  of  digestive  troubles  really 
suffer  from  diseases  of  other  organs;  while  sometimes 
affections  of  the  stomach  exist  in  connection  with 
other  diseases  of  organic  nature.  After  having  ascer- 
tained the  condition  of  the  thoracic  organs  a  special 
examination  of  the  abdominal  organs  should  then  be 
instituted. 

Inspection. 

The  general  appearance  of  the  patient  very  often 
affords  us  an  idea  of  the-nature  of  his  illness,  especially 
with  regard  to  its  severity,  whether  we  have  to  deal 
with  some  serious  trouble  or  with  an  affection  of  only 
a  functional  character.  The  emaciated  and  sallow 
look  of  a  patient  suffering  from  cancer  and  the  well- 
nourished  rosy  face  of  a  patient  with  a  neurotic  dis- 
turbance of  his  digestion  are  striking  examples  of 
what  can  be  made  out  by  a  mere  glance. 

We  must  inspect  first  the  oral  cavity  and  inform 
ourselves  about  the  condition  of  the  teeth,  gums, 
tongue,  uvula,  and  pharynx.  Defective  and  carious 
teeth  sometimes  give  origin  to  gastric  disorders. 

In  olden  times  the  tongue  was  regarded  as  a  mirror 
of  the  stomach,  so  that  every  gastric  affection  was 
judged  by  the  aj)pearance  of  the  tongue.  Although 
nowadays  we  know  that  there  are  conditions  in  which 
the  stomach  is  diseased  and  still  the  tongue  has  a  nor- 
mal appearance,  and  vice  versa  conditions  where  the 
stomach  is  in  no  way  affected   and   still  the  tongue 


INSPECTION.  23 

heavily  coated,  it  is  nevertheless  true  that  many  gas- 
tric affections  go  hand-in-hand  with  changes  in  the 
appearance  of  the  tongue.  The  tongue  may  at  times 
he  thickly  furred  or  may  appear  very  shiny  and  gray ; 
sometimes  it  may  show  indentations  around  its  margin, 
sometimes  again  it  may  look  red  and  dry  like  leather. 

In  the  pharynx  we  sometimes  discover  catarrhal 
conditions  or  swollen  follicles. 

The  uvula  is  sometimes  very  much  elongated  and 
may  in  this  way  give  cause  to  some  reflex  digestive 
troubles. 

The  inspection  of  the  neck  will  sometimes  disclose  a 
swelling  to  the  left  of  the  larynx,  which  increases  after 
partaking  of  food  and  may  he  due  to  a  diverticulum  of 
the  oesophagus. 

The  inspection  of  the  abdomen  should  never  be 
neglected.  The  contours  of  the  stomach  are  at  times 
visible  in  patients  with  thin  abdominal  walls,  and  es- 
pecially if  the  stomach  is  either  extraordinarily  large 
or  displaced  downward.  Osier'  not  long  ago  laid 
much  stress  upon  this  simple  method  of  examination, 
and  ascertained  that  in  many  instances  we  can  make 
the  diagnosis  of  a  dilated  stomach  by  mere  inspection. 
I  can  corroborate  Osier's  view,  as  I  have  had  occasion 
in  several  instances  of  making  a  diagnosis  of  ectasia 
ventriculi  by  the  mere  visible  outlines  of  the  stomach. 
Tumors  may  sometimes  be  seen  and  recognized  as 
such.  Their  position  will  already  give  us  a  clew  as  to 
what  organ  they  belong.  By  attentive  inspection  we 
sometimes  notice  peristaltic  waves  passing  from  left  to 

'  W.  Osier:  "Lectures  on  Diagnosis  of  Abdominal  Tumors." 
New  York  Medical  Journal,  1894. 


24  DISEASES   OF  THE   STOMACH. 

right  over  a  large  area  in  the  upper  part  of  the  ab- 
domen, which  are  caused  by  the  muscular  action  of 
the  stomach.  If  these  waves  are  intense  in  character 
and  persist  for  some  length  of  time,  then  we  have  to 
deal  with  the  condition  called  "peristaltic  restlessness" 
of  the  stomach.  Smaller  peristaltic  waves  may  be 
seen  occasionally  in  the  lower  part  of  the  abdomen 
and  be  due  to  a  peristaltic  movement  of  the  small 
intestine. 

Palpation. 

Palpation  is  one  of  the  best  and  most  important 
methods  of  examination.  A  good  clinician  is  as  a 
rule  an  artist  in  palpation.  The  best  way  to  prac- 
tise this  method  is  as  follows:  The  patient  should 
assume  an  easy,  comfortable,  recumbent  position;  the 
physician  stands  to  the  right  of  the  patient  and  places 
his  right  hand,  which  should  not  be  cold,  flat  upon  the 
abdomen.  Palpation  is  first  practised  with  the  tips  of 
the  fingers  without  exerting  much  pressure.  The  en- 
tire abdomen  may  be  examined  in  this  manner  by 
moving  the  hand  from  the  left  lower  border  of  the 
ribs  down  to  the  left  iliac  region,  going  then  to  the 
right  iliac  region  and  then  up  to  the  margin  of  the  ribs 
on  the  right  side.  If  the  patient  contracts  his  abdomi- 
nal walls  too  much,  it  is  best  to  divert  his  attention 
from  the  examination  by  conversing  with  him  upon 
other  topics.  Very  often  then  the  abdominal  walls  will 
become  more  relaxed  and  palpation  is  rendered  pos- 
sible. Pay  attention  to  any  resistance  you  encounter, 
also  the  sensitiveness  or  tenderness  of  the  different  re- 
gions.    By  this  method  of  light  and  tender  palpation 


PALPATION.  25 

we  may  discover  a  tumor  and  determiDe  its  positioc, 
size,  consistence,  as  well  as  its  mobility.  In  examin- 
ing the  lower  part  of  the  abdomen  we  also  palpate  the 
inguinal  region  and  ascertain  whether  there  are 
swollen  glands  or  not. 

To  determine  the  position  of  the  abdominal  organs 
it  is  always  advisable  to  make  use  of  both  hands. 
The  left  hand  should  push  the  organ  or  region  to  be 
examined  toward  the  jDalpating  right  hand.  The 
colon  is  very  often  felt  somewhat  below  the  navel  run- 
ning transversely  across  the  abdomen  as  a  ribbon-like 
body.  The  pulsating  aorta,  lying  in  the  median  line  of 
the  body  somewhat  above  the  navel,  is  also  frequently 
very  clearly  felt.  The  spleen,  if  enlarged  or  displaced, 
can  be  distinctly  explored  especially  during  a  deep  in- 
spiration, the  left  hand  of  the  examiner  pressing  the 
left  hypochondriac  region  downward  and  the  right 
hand  palpating  just  below  the  margin  of  the  left  ribs. 
The  kidneys  are  accessible  to  palpation  if  they  are  dis- 
placed downward  or  are  movable.  In  examining  the 
right  kidney  the  left  hand  of  the  physician  is  placed 
behind  the  right  lumbar  region  of  the  patient,  pressing 
this  part  somewhat  upward,  while  his  right  hand  lies 
flat  upon  the  right  hypochondriac  region,  the  patient 
being  requested  to  take  a  deep  breath.  In  examining 
the  left  kidney  the  position  of  the  hand  is  reversed. 
The  liver  can  be  palpated  when  enlarged  or  when  it  is 
prolapsed. 

Palpation  luith  Exertion  of  Pressure. — ^This  can  be 
done  with  one  or  two  fingers.  The  object  of  this 
method  of  examination  is  to  test  the  degree  of  sensi- 
tiveness, tenderness,  or  pain  fulness  of  different  regions 


26  DISEASES  OF  THE   STOMACH. 

of  the  abdomen.  In  this  manner  the  circumscribed 
painful  area  of  an  existing  ulcer  may  be  discovered  or 
the  diffused  tenderness  of  the  whole  gastric  region 
that  is  often  met  with  in  inflammatory  conditions  of 
this  organ.  Boas'  has  devised  an  algesimeter  for  the 
purpose  of  indicating  at  what  degree  of  pressure  pain 
is  experienced  by  the  patient.  It  is  provided  with  a 
scale  giving  the  different  jDressures  in  weights;  thus 
a  pressure  amounting  to  5  or  10  kgm.  in  weight 
causes  pain  only  in  catarrhal  conditions,  whereas  in 
ulcer  of  the  stomach  a  weight  of  only  half  a  kilo- 
gram produces  intense  pain.  As  a  rule,  I  think  we 
can  dispense  with  this  instrument.  The  amount  of 
pressure  exerted  and  felt  b}^  the  hand  is  thoroughly 
suflBcient  to  an  experienced  practitioner. 

Percussion. 

In  percussing  the  stomach  it  is  best  to  use  finger 
percussion  and  to  practise  this  procedure  without  much 
force.  The  object  of  this  method  of  examination  is  to 
determine  if  possible  the  situation  of  the  stomach. 
This  organ,  being  as  a  rule  partly  filled  with  air,  gives 
a  tympanitic  sound  on  percussion.  It  is,  however, 
quite  difficult  to  ascertain  its  exact  size,  as  the  large 
intestine  may  be  filled  with  gas  and  also  give  the  same 
tympanitic  sound.  For  this  reason  Piorry^  suggested 
filling  the  stomach  with  water  before  resorting  to  per- 
cussion. The  stomach  when  filled  in  this  manner  gives 
a  dull  sound,  which  can  then  be  more  easily  differen- 
tiated from  the  tympanitic  sound  gf  the  colon.     The 

'  J.  Boas  :  "  Diagnostik  nnd  Tlierapie  der  Magenkrankheiten, "  i., 
p.  75,  Leipzig,  1894. 

'^Piorry:  "Die  mitt§lbare  Percussion,"  "Wiirzburg,  1828. 


PERCUSSION.  27 

best  way  to  examine  the  patient,  according  to  Piorry, 
is  to  let  him  drink  large  quantities  of  water  (about  one 
litre)  and  to  examine  him  when  standing.  The  same 
method  was  frequently  used  afterward  by  Penzoldt.' 
Behio/  who  is  also  a  strong  advocate  of  this  method, 
giA^es  the  water,  however,  in  fractional  quantities. 
The  patient  first  drinks  one-fourth  litre  of  water  and 
is  then  examined ;  he  now  takes  the  same  amount,  after 
which  a  second  examination  is  made,  and  so  on  until 
the  whole  litre  of  water  has  been  ingested.  The  area 
of  dulness  that  is  found  on  the  abdominal  wall  is 
marked  each  time  with  a  lead  pencil.  It  is  necessary 
to  note  whether  the  lower  limit  of  this  area  has 
extended  considerably  farther  down  after  the  addition 
of  each  portion  of  water.  In  dilated  stomachs  the 
lower  limit  of  this  area  will  be  found  quite  far  down 
below  the  navel,  whereas  in  normal  stomachs  the  lower 
limit  will  usually  be  above  it.  According  to  Boas'  the 
Dehio  method  furnishes  a  test  of  the  tonicity  of  the 
gastric  muscle.  Boas  asserts  that  in  all  cases  where 
the  lower  limit  of  the  dull  area  descends  quickly  after 
the  further  addition  of  the  water  there  exists  a  kind 
of  weakness  or  atony  of  the  stomach. 

As  the  results  obtained  by  the  above  methods  of 
percussion  are  not  always  sufficient  and  clear,  several 
other  means  have  been  introduced  w^hich  permit  of  a 
better  recognition  of  the  size  of  the  stomach.  The 
first,  and  so  to  speak  clinical  method,  applied  for  this 

1  Penzoldt :  "  Die  Mageuerweiterung, "  Erlangen,  1877. 

-Dehio-  "Zur  physikalipclien  Diagnostik  der  meclianisclieu  In- 
sufficienz  des  MageDs."  Verhandl.  des  VIT.  Congresses  f.  innere 
Medicin.  1888. 

^  J.  Boas  :  Loc.  cit.,  p.  85. 


28  DISEASES   OF   THE   STOMACH. 

purpose  is  that  devised  by  Frericbs'  and  consists  in 
filling  the  stomach  with  carbonic-acid  gas.  It  is  done 
in  the  following  way:  The  patient  first  takes  2  gm. 
of  sodium  bicarbonate  in  a  half-glassful  of  water, 
then  2  gm.  of  tartaric  acid  also  dissolved  in  the  same 
quantity  of  water.  The  sodium  bicarbonate  coming 
in  contact  with  the  tartaric  acid  in  the  stomach  gives 
rise  to  the  development  of  carbonic-acid  gas,  which 
distends  the  organ.  The  contours  of  the  stomach 
are  now  sometimes  visible  through  the  abdominal 
wall.  If  this  is  not  the  case  percussion  is  now  aT)plied 
in  order  to  map  out  the  tympanitic  area.  This  method 
can  certainly  be  very  frequently  applied  and  will  prove 
useful  to  the  practitioner.  It  has,  however,  two  dis- 
advantages, one  being  that  the  quantity  of  gas  is 
sometimes  insufficient,  and  the  other  that  it  might  be 
too  large  and  give  the  patient  a  feeling  of  pressure  in 
the  stomach.  In  order  to  overcome  these  difficulties, 
Runeberg"  first  made  use  of  a  tube  and  a  rubber  bulb 
attachment  that  allowed  the  forcing  of  air  into  the 
stomach.  Here  the  quantity  of  air  can  be  easily  regu- 
lated, the  stomach  examined  in  different  states  of  dis- 
tention, and  afterward  the  air  removed  through  the 
tube.  This  is  the  method  of  examination  most 
commonly  applied  and  in  dail}'  use. 

Auscultatory  Percussiofi. 
Auscultation  by  means  of  the  stethoscope  to  the 
sounds  produced  by  percussion  has  been  practised  by 

'  Frericlis  :  Cited  from  H.  v.  Ziemssen,  "'Klin.  Vortrage, "  1883, 
No.  12,  p.  13. 

''Runeberg:  "Ueber  kunstliche  Aufblabung  des  Magens  und 
des  Dickdarms  durch  Einp-impen  vonLuft."  Deutsches  Archiv  f. 
klin.  Medicin,  vol.  34,  p.  460. 


THE   SPLASHING   SOUND.  29 

several  observers,  and  recently  warmly  recommended 
by  W.  Pepper.'  The  patient  holds  the  bulb  of  the 
stethoscope  and  moves  it  about  while  the  physician 
percusses  and  maps  out  the  abdominal  organs. 

SOUXDS    OF   THE    StOMACH. 

Tlie  Splashing  Sound  {Clapotage) . 

Whenever  the  stomach  is  filled  partly  with  liquid 
and  partly  with  gas  it  is  possible  to  produce  a 
splasliing  sound  by  striking  the  abdominal  wall  in  the 
gastric  region.  This  sound  is  distinctly  audible  at  a 
short  distance  from  the  patient.  Bouchard  ^  made  an 
extensive  study  of  this  splashing  sound  and  considered 
it  a  sign  of  great  diagnostic  value  in  dilatation  of  the 
stomach.  Nowadays  we  do  not  attach  so  much  im- 
portance to  the  splashing  sound  j^erse.  Dr.  A.  Eose"" 
and  myself  have  recently  examined  a  hundred  cases 
for  the  existence  of  this  symptom  and  found  it  present 
in  many  persons  not  troubled  in  any  way  with  diges- 
tive disturbances.  The  importance  of  the  splashing 
sound,  in  my  opinion,  is  that  wherever  it  is  present  or 
can  be  produced,  it  allows  us  to  ascertain  the  position 
of  the  stomach.  In  dilated  stomachs  this  sound  can 
be  produced  over  a  very  large  area  of  the  abdominal 
wall,  extending  sometimes  far  down  to  the  pubes. 

Another  point  of  importance  seems  to  me  to  be  the 

'  W.  Pepper:  "The  Diagnosis  and  Treatment  of  Dilatation  of 
the  Stomach, "  Medical  Eecord,  May  9th,  1896. 

^  Bouchard  :  Gaz.  hebdomadaire  de  Medecine  et  de  Chirurgie, 
1884. 

2  A.  Rose  :  "What  is  the  Significance  of  the  Splashing  Sound  of 
the  Stomach?"     New  York  Medical  Journal,  June  loth,  1895. 


30  DISEASES   OF   THE   STOMACH. 

ease  with  which  the  splashing  sound  can  be  repeatedly 
produced.  In  cases  of  gastric  dilatation  and  when  the 
walls  of  the  stomach  are  relaxed,  even  light  tapping  of 
the  abdomen  will  always  give  rise  to  this  sound.  In 
normal  conditions  a  splashing  sound  can  sometimes  be 
produced  by  striking  the  abdomen  with  the  hand,  but 
on  repeating  this  procedure  at  once  we  will,  as  a 
rule,  fail  to  produce  it,  as  the  stomach  then  con- 
tracts more  or  less,  and  it  is  necessary  to  wait  quite  a 
while  until  it  has  become  relaxed  before  this  sound 
can  be  again  evoked. 

On  examining  the  patient  in  the  fasting  condition 
the  existence  of  the  splashing  sound  is  of  value  in  show- 
ing that  the  stomach  is  not  empty  and  hence  abnormal. 
This,  however,  is  not  a  reliable  sign  and  I  perfectly 
agree  with  Debove  and  Eemond  '  that  sometimes, 
although  rarely,  the  stomach  may  be  found  empty 
notwithstanding  a  splashing  sound.  Moreover,  the 
absence  of  this  phenomenon  in  the  fasting  condition 
does  not  by  any  means  warrant  the  conclusion  that 
the  organ  is  empty.  In  many  instances  I  was  able 
to  persuade  myself  that  the  stomach  contained  con- 
siderable quantities  of  food  notwithstanding  the  ab- 
sence of  the  splashing  sound. 


1.  Deglutition  Sounds. 

The  deglutition  sounds  were  first  described  by 
Kronecker  and  Meltzer.'     When  drinking  there  is  at 

'  Debove  et  Remond  :  "Traite  des  maladies  de  I'estoraac,"  Paris. 

''S.  J.  Meltzer:  "Schluckgerausclie  im  Scrobiculus  Cordis  und 
ihre  physiologische  Bedeutung."  Centralbl.  f.  die  medicin.  Wis- 
sensch.,  1883,  No.   1. 


SOUNDS    OF    THE    STOMACH,  31 

times  a  sound  to  be  heard  simultaneously  with  the  act 
of  deglutition  which  is  termed  the  first  deglutition 
sound.  More  frequently  a  second  sound  is  noted  about 
seven  seconds  after  the  act  of  deglutition.  Both  sounds 
can  be  heard  at  the  ensiform  process  either  by  placing 
the  ear  at  that  spot  or  by  means  of  a  stethoscope.  As 
a  rule  only  the  second  sound  is  perceptible.  If  the  first 
sound  is  present,  the  second  sound  may  also  appear  or 
at  times  may  be  absent.  The  presence  of  these  deglu- 
tition sounds  permits  us  in  some  measure  to  judge 
about  the  permeability  of  the  cardia,  and  their  main 
diagnostic  value  consists  in  demonstrating  their  ab- 
sence, for  then  we  are  entitled  to  presume  that  the 
ingested  liquid  has  not  reached  the  stomach,  but  has 
remained  in  the  oesophagus  above  the  cardia.  This  is 
most  often  the  case  in  strictures  of  the  cardia,  although 
occasionally  this  condition  might  be  caused  by  a 
deficiency  in  the  peristaltic  motion  of  the  oesophagus. 

2.  When  the  patient  is  drinking  we  can  hear,  by 
putting  our  ear  to  the  abdominal  wall  corresponding 
to  the  gastric  region,  a  kind  of  dripping  sound,  arising 
from  the  passing  down  of  the  fluid  along  the  gastric 
wall.  By  mapping  out  exactly  the  spots  over  which 
the  sounds  can  be  heard  while  the  patient  is  drinking 
we  may  at  times  be  able  to  determine  the  contour  and 
size  of  the  stomach  and  form  an  idea  whether  the 
organ  is  enlarged  or  not. 

3.  O.  Eosenbach'  has  suggested  that  the  size  of  the 
stomach  may  be  ascertained  by  giving  the  patient 
some  water  to  drink  and  then  blowing  in  some  air  by 

'  O.  Rosenbach  :  "  Der  Mechanismiis  und  die  Diagnose  der  Magen- 
insufiScienz. "     Volkmann's,"SammL  klin.  Vortrage, "  1878,  No.  153. 


32  DISEASES   OF   THE   STOMACH. 

means  of  a  stomach  tube.  As  soon  as  the  end  of  the 
tube  reaches  the  level  of  the  water  and  ah'  is  blown  in, 
a  bubbling  sound  arises,  which  can  be  heard  by  placing 
the  ear  over  the  corresponding  part  of  the  abdominal 
wall,  and  the  exact  site  marked  out.  As  soon  as  the 
end  of  the  tube  is  above  the  level  of  the  water  one 
can  hear  only  the  air  striking  the  stomach  wall,  but 
unaccompanied  with  the  bubbling  sounds.  By  alter- 
nately raising  and  lowering  the  tube  the  height  of  the 
level  of  the  fluid  can  be  approximately  determined. 

■i.  The  succussion  sound.  This  sound  was  first  de- 
scribed and  utilized  for  diagnostic  purposes  by  Hippoc- 
rates. The  method  consists  in  shaking  the  patient 
and  listening.  If  the  stomach  is  considerably  enlarged 
and  contains  liquid  and  gas,  splashing  sounds  are  pro- 
duced and  can  be  heard  at  quite  a  distance  from  the 
patient.  Such  sounds  also  occur  under  other  circum- 
stances if  the  patients  change  their  position,  for  in- 
stance, when  turning  from  one  side  to  another  in  bed, 
and  give  rise  to  considerable  annoyance. 

5.  Gurgling  sounds  may  be  heard  when  the  stomach, 
which  does  not  contain  any  liquid  but  some  air  or  gas, 
suddenly  contracts.  Thus  every  one  is  acquainted  by 
personal  experience  with  the  sound  generated  in  the 
stomach  when  one  is  very  hungry.  As  the  Germans 
say:  "The  stomach  growls." 

6.  Eespiratory  sounds.  Sounds  arising  synchro- 
nously with  inspiration.  These  are  heard  especially  in 
cases  of  gastric  dilatation  or  of  gastroptosis,  or  where 
the  stomach  occupies  a  vertical  position,  particularly 
in  women  who  wear  corsets.  The  sound  may  as- 
sume two  characters,   according  to  its  mode  of  pro- 


GASTROSCOPY.  33 

duction:  One  sound  is  produced  during  the  act  of 
inspiration  by  the  gliding  of  the  abdominal  wall  over 
the  stomach  when  distended  with  gas.  It  is  similar  to 
the  sound  that  is  produced  by  the  cello,  and  may  per- 
haps be  explained  by  reason  of  the  gas  being  compressed 
and  forming  a  resounding  surface  which  is  set  into 
vibration  by  the  movements  of  the  abdominal  wall. 
The  second  sound  is  caused  by  the  rise  and  fall  of 
liquid  during  the  act  of  respiration.  It  has  a  some- 
what si)lashing  or  squirting  character.  These  sounds 
are  very  frequently  met  with  and  especially  heard  in 
ladies'  society. 

7.  Sizzling  sounds.  These  can  be  heard  only  on 
direct  auscultation,  and  are  produced  by  gas  forming 
quickly  in  the  stomach.  They  are  normally  found 
after  the  introduction  into  the  stomach  of  bicarbonate 
of  soda  and  tartaric  acid,  carbonic-acid  gas  being  set 
free  and  giving  rise  to  these  sounds.  Pathologically 
they  are  developed  spontaneously  and  are  a  positive 
sign  of  fermentation  going  on  in  the  stomach  and  con- 
sequently of  stagnation  of  food. 

8.  Einging  sounds.  These  have  been  described  by 
Laker'  in  a  case  of  dilatation  of  the  stomach.  They 
are  synchronous  with  the  heart  sounds  and  can  be 
heard  at  quite  a  distance  from  the  patient. 

Gastroscopy. 

The  object  of  this  method  of  examination  is  to  look 
into  the  stomach  and  to  ascertain  the  condition  of  the 

'Laker:  "Ueber  ein  rhytmisches  Klangphanomen  desMagens." 
Wiener  med.  Presse,  1889,  Nos.  43  and  44. 
3 


34  DISEASES    OF   THE    STOMACH. 

gastric  mucosa.  This  method  was  inaugurated  hy 
Mikulicz'  in  1881.  The  gastroscope  is  similar  in  shape 
and  construction  to  the  cystoscope,  but  much  larger  iu 
size.""  This  method  of  examination  has  not,  however, 
come  into  practice,  and  will  hardly  ever  prove  of  much 
value;  the  chief  reason  being  that  a  stiff  metal  tube 
has  to  be  inserted  into  the  stomach,  which  is  hard  to 
manage  and  causes  great  discomfort  to  the  patient. 
As  in  all  cases  in  which  we  have  to  deal  with  cancer 
or  with  other  grave  lesions  of  the  stomach,  there  is 
always  suspicion  of  an  ulcer,  this  means  of  exami- 
nation would  not  only  be  inconvenient,  but  also  dan- 
gerous on  account  of  the  risk  of  perforation. 

Gastrodiaphaxy,  or  Traxsillumixatiox  of  the 
Stomach. 

The  method  of  transilluminating  living  tissues  was 
first  applied  by  Cazenave  in  1S15.  Milliot*  in  1867 
tried  to  transilluminate  the  stomach  of  animals,  and 
used  for  that  purpose  a  narrow  glass  tube  in  which 
there  were  two  thin  platinum  wires  connected  with  the 
electrodes  of  a  Middeldorpf's  apparatus.  In  1889  I' 
succeeded  in  transilluminating  the  stomach  of  human 

•  Mikulicz  :  "  Ueber  Gastroskopie  und  CEsophagoskopie.  '  "Wiener 
med.  Presse,  1881,  No.  45. 

2  Remark  :  Recently  Th.  Rosenheim,  of  Berlin,  has  constructed  a 
new  oesophagoscope  and  gastroscope.  For  details  see  "Ueber  die 
Besichtigung  der  Cardia  nebst  Beraerkungen  tiber  Gastroskopie." 
Deutsche  med.  Wochenschr. ,  1895.  No.  45. 

^Milliot:  Schmidt's  Jahrbucher,  Bd.  136,  p.  143. 

••Max  Einhorn :  "Die  Gastrodiaphanie. "  New  Yorker  med. 
Monatsschrift,  November,  1889.  "Ou  Gastrodiaphany."  New  York 
Medical  Journal,  December  8d,  lS9'i.  The  Journal  of  the  American 
Medical  Association,  1893. 


G  ASTRODI APH  ANY . 


35 


beings  by  means  of  a  soft-rubber  tube  at  one  end  of 
which  is  fastened  an  Edison  lamp  by  means  of  a  small 
metal  mounting.  From  here  conducting  wires  run  to 
the  battery.  At  some  distance  from  the  rubber  tube 
there  is  a  current  interrupter.     I  have  called  this  ap- 


FiG.  5. — ^The  Gastrodiaphane  CEinhorn). 

paratus  the  gastrodiaphane  and  the  method  of  trans- 
illuminating  the  stomach,  gastrodiaphany. 

The  aims  of  gastrodiaphany  are:  1.  To  ascertain 
the  exact  position  and  the  size  of  the  stomach.  2.  To 
recognize  tumors  or  thickenings  of  the  front  wall  of 
the  stomach  by  their  lack  of  translucency.     Of  late 


36 


DISEASES   OF   THE   STOMACH. 


many  investigators  have  busied  themselves  vrith  this 
method  of  examination:  Heryng  and  Eeichmann,' 
Renvers,*  Pariser/  Stewart,  Ewald,  Kuttner  and 
Jacobson.*  Martins  and  Meltzing,"  Stockton,  Frieden- 
wald,^  M.  Manges,'  and  many  others,  and  all  have  come 


Fig.  6.— Transilluminated  Zone  of  a  Normal  Stomach  (51.  S.).    The  dotted  area  in 
the  centre  shows  the  spot  which  was  more  luminous,  being  nearer  to  the  lamp. 

to  about  the  same  conclusion  as   I  have.     Meltzing 
especially  has  written  a  very  extensive  and  elaborate 

'  Heryng  und  Reichmann  :  Therap.  Monatshefte,  1892. 

^Renvers:  Ver.  f.  innere  Medicin,  April  4th,  1892. 

sPariser:  Berl.  klin.  AVochenschr. ,  1892,  No.  32. 

■•Kuttner  and  Jacobsohn  :  Berl.  klin.  Wochenschr.,  1893,  No.  39. 

^Meltzing:  Zeitschr.  f.  klin.  Medicin,  1895. 

« J.  Friedenwald  :  "  Electric  Illumination  of  the  Stomach. "  Mary- 
land Med.  Joum.,  Jan.  20th,  1894. 

'  M.  Manges  :  "  The  Value  of  the  Modem  Diagnostic  Methods  in 
Diseases  of  the  Stomach."'     Medical  Record,  Februarj' 2d,  1895. 


GASTRODI APH  AN  Y . 


37 


paper  on  gastrodiaphany  and  has  tried  to  determine 
the  normal  position  of  the  stomach  by  this  means. 

Method  of  Examination. — The  patient,  in  a  fasting 
condition,  drinks  one  to  two  glassfuls  of  water.  The 
apparatus,  lubricated  with  glycerin  or  simply  moist- 
ened in  water,  is  then  inserted  into  the  stomach  and 


Fig.  7. — ^Transilluminated  Zone  of  a  Dilated  Stomach  (patient  Wm.  U.). 


connected  with  the  battery.  The  examination  is  made 
in  a  perfectly  dark  room,  either  in  the  standing  or  re- 
cumbent position  of  the  patient.  The  stomach  trans- 
mits the  electric  light  through  the  abdominal  walls, 
and  it  thus  becomes  visible  as  a  red  zone  at  that  place 
of  the  abdomen  which  corresponds  the  position  of  the 
stomach.  In  case  the  gastric  front  wall  is  occupied 
by  a  tumor,  the  latter  will  not  transmit  the  light  and 


38 


DISEASES  OP   THE   STOMACH. 


will  be  recognizable  as  a  shady  spot  within  the  red  zone 
of  the  transilluminated  organ. 

The  accompanying  illustrations  obtained  from  pa- 
tients whose  stomachs  have  been  transilluminated 
by  the  gastrodiaphane  in  different  conditions  explain 
themselves. 


Fig.  8.— Transilluminated  Zone  of  a  Dilated  Stomach  (patient  H.  O.).  The  dotted 
area  in  the  centr  shows  the  spot  which  was  more  luminous,  being  nearer  to  the 
lamp. 


Roentgen  Rays. 

Whether  the  Eoentgen  rays  will  be  of  material  aid 
in  the  examination  of  the  stomach,  is  quite  difficult  to 
state  at  the  jDresent  time.  As  we  have  just  seen,  the 
gastrodiaphane  enables  us  to  recognize  the  shape  and 
situation  of  the  stomach  and  occasionally  also  tumors 


EXAMINATION   OF   THE   FUNCTIONS.  39 

favorably  situated  for  this  procedure.  Whether  the 
X-rays  of  Eoentgen  will  do  more,  further  investiga- 
tions will  have  to  demonstrate. 

Examination  of  the  Functions  of  the  Stomach. 
Secretory  Function. 

Ewald  and  Boas*  have  studied  the  normal  condition 
of  gastric  secretion  in  man.     According  to  their  ob- 


FiG.  9.— Transilluminated  Zone  of  the  Stomach  in  Gastroptosis  (from  Mrs.  P.  F.). 

servations,  as  soon  as  food  enters  the  stomach,  this 
organ  begins  to  secrete  its  specific  juice  and  continues 
to  do  so  until  the  food  has  passed  into  the  intestine. 
During  the  last  period,  however,  the  secretion  is  but 

'  Ewald  and  Boas  :  Virchow's  Archiv,  vol.  101,  p.  325. 


40 


DISEASES   OF   THE   STOMACH. 


very  slight.  That  is  the  reason  why  examinations  of 
the  gastric  contents  reveal  different  results  if  made  at 
various  periods  after  partaking  of  food.  In  order  to 
be  able  to  judge  in  an  exact  manner  whether  the  gas- 
tric secretion  is  normal  or  not,  we  must  always  make 
the  examination  under  equal  conditions,  that  is,  after 


Fig.  10.— Result  of  Gastrodiaphany  in  a  Patient  with  Carcinoma  of  Stomach.   Dark 
area  represents  situation  of  tumor. 

a  certain  meal.     Several  test  meals  have  been  proposed 
for  this  purpose. 


1.     Leuhe-BiegeV s   Test  Dinner. 

The  oldest  form  of  test  meal  is  the  test  dinner  of 
Leube  and  Eiegel.     This  consists  of  a  large  plate  of 


EXAMINATION   OF   THE   FUNCTIONS.  41 

soup  (about  400  c.c),  a  large  portion  of  meat  (beef- 
steak or  something  of  that  kind),  some  potatoes,  and  a 
roll.  The  time  for  examination  is  about  three  to  four 
hours  after  the  partaking  of  this  meal. 

2.   The  Test  Breakfast  of  Ewald  and  Boas. 

This  is  taken  in  the  morning  in  a  fasting  condition 
and  consists  of  one  to  two  rolls  (35-70  gm.)  and  one 
cup  of  tea  or  water  (300-400  c.c).  Time  for  examin- 
ation, about  one  hour  after  the  meal. 

3.   Germain  See''s  Test  Meal. 

This  consists  of  60-80  gm.  of  scraped  meat  and 
100-150  gm.  of  white  bread.  Examination  takes 
place  two  hours  after  the  ingestion  of  the  food. 

4-.  Klemperer^s  Test  Meal. 

This  consists  of  one  pint  of  milk  and  two  rolls.  Ex- 
amination takes  place  two  hours  afterward. 

The  two  test  meals  that  are  mostly  in  use  are  the 
Leube-Riegel's  test  dinner  and  Ewald-Boas'  test 
breakfast.  In  1888  I'  made  a  comparative  study  of 
the  results  obtained  three  to  four  hours  after  the  test 
dinner,  and  those  derived  in  the  same  cases  one  hour 
after  Ewald's  test  breakfast.  In  some  persons  I  was 
able  to  find  free  hydrochloric  acid  after  the  test  break- 
fast, but  not  after  the  test  dinner.  Besides,  the  degree 
of  acidity  was  more  constant  in  the  same  individual 
after  the  test  breakfast  than  after  the  dinner.     More- 

'Max  Einhorn :  "Probemittagbrod  oder  Probefriihstuck." 
Berl.  klin.  Wochenschr.,  1888,  No.  32. 


42  DISEASES   OF   THE   STOMACH. 

over,  we  are  able  to  recognize  some  remnants  of  food 
from  the  previous  day  much  more  easily  after  the  test 
breakfast  than  after  the  test  dinner.  As  the  test 
breakfast  consists  only  of  water  and  rolls,  any  other 
particles  of  food  found  in  the  gastric  contents,  as  for 
instance  meat,  asparagus,  would  indicate  that  these 
substances  have  been  left  there  from  a  previous  meal. 
The  test  dinner  being  quite  a  complicated  meal,  does 
not  allow  us  to  recognize  this  so  clearly,  and  it  is 
necessary  to  examine  the  patient  again  in  a  fasting 
condition  in  case  there  is  suspicion  that  the  motor  func- 
tion of  the  stomach  is  impaired.  These  advantages 
have  also  been  recognized  by  other  authors,  and  now- 
adays almost  all  agree  in  preferring  the  test  breakfast 
to  the  other  test  meals. 

The  stomach  contents  may  be  obtained  for  purpose 
of  examination  by  the  following  methods : 

By  means  of  the  soft-rubber  tube  and  either  as- 
piration or  expression.  In  using  the  tube  it  is  best  to 
have  one  with  several  openings  at  the  lower  end  and  to 
attach  a  small  glass  tube  about  three  to  five  inches  in 
length  to  the  upper  end  (see  Fig.  11).  The  tube  is 
first  immersed  in  a  pitcher  of  warm  water.  The  pa- 
tient is  provided  with  a  bib  or  towel  around  his  neck 
and  sits  on  a  chair,  holding  a  wide-mouthed  bottle  in 
his  left  hand,  near  his  chest ;  the  physician  takes  the 
tube  from  the  pitcher,  places  the  glass  end  piece  into 
the  bottle,  tells  the  patient  to  open  his  mouth,  and  in- 
serts the  tube,  pushing  it  forward  into  the  pharynx. 
(The  physician  need  not  insert  his  finger  into  the 
mouth  of  the  patient.)  The  patient  is  now  told  to 
swallow  once  or  twice,  and  the  tube  is  rapidly  pushed 


EXAMINATION   OF    THE    FUNCTIONS. 


43 


with    the    right     hand     into     the     stomach     (about 
44-4:5  cm.). 

In  using  aspiration,  one  can  either  attach  a  Politzer 
bulb  over  the  glass  piece  (Ewald)  or  Boas'  aspirator, 


Fig.  11.— Ewald's  Stomach  Tube. 


which  consists  of  a  rubber  bulb  having  two  soft-rub- 
ber ends  provided  with  a  clamp  (see  Fig.  12).  The 
bulb  is  first  compressed  and  then  released,  and  in  this 
way  aspiration  is  secured  and  the  bulb  fills  itself  with 
the  gastric  contents. 

Ewalcl-Boas''  expression  method :  The  expression 
method  consists  in  having  the  patient  exert  pressure 
upon  his  stomach  by  means  of  his  abdominal  muscles. 
This  is  best  done  by  telling  the  patient  first  to  inspire 
deeply  and  then  to  compress  his  abdominal  walls  in  the 


Fig.  13. — Boas'  Aspirator. 


same  manner  as  during  defecation.  The  pressure  ex- 
erted in  this  way  upon  the  gastric  contents  expels 
them  through  the  tube  into  the  bottle.  This  expres- 
sion method  is  now  almost  exclusively  practised  every- 


44  DISEASES    OF   THE    STOMACH. 

where.  It  is  the  easiest  and  best  way  of  obtaining  the 
gastric  contents. 

Before  removing  the  tube,  it  is  necessary  to  occlude 
the  glass  opening  with  a  finger  of  the  right  hand  and 
to  withdraw  the  instrument  quickly  from  the  stomach. 
(By  closing  the  opening  we  avoid  the  return  of  some 
of  the  food  particles  contained  within  the  tube  into  the 
oesophagus  or  pharynx;  the  tube  is  then  emptied  into 
the  bottle  containing  the  stomach  contents.) 

The  ingesta  obtained  in  the  above-described  way 
one  to  one  and  a  half  hours  after  the  test  breakfast 
are  then  filtered,  and  the  filtrate  is  subjected  to  the 
following  tests:  1.  Reaction.  "2.  Hydrochloric  acid. 
3.  Lactic  acid.  4.  Acidity.  5.  Propeptone.  6.  Pep- 
tone. 7.  Pepsin.  S.  Eennet  ferment.  9.  Dextrin. 
10.  Erythrodextrin.    11.  Achroodextrin.     12.  Maltose. 

Examination  of  the  Ingesta. 

1.   The  Reaction 

Is  determined  by  means  of  litmus  paper  (blue  and 
red).  If  the  filtrate  is  acid  it  turns  blue  litmus  paper 
red. 

2.  Hydroch  loric  Acid. 

Many  coloring  matters  undergo  some  change  when 
brought  together  with  even  weak  solutions  of  free 
hydrochloric  acid.  Methyl  violet  (weak  one-per-cent. 
solution)  turns  blue;  fuchsin  is  slightly  discolored; 
tropseolin  (saturated  solution)  turns  from  yellow  to 
dark  red-brown ;  benzo-purpurin  turns  from  intense 
red  to  light  red;  Congo  red  (one-per-cent.  solution)  or 
Congo  pajDcr  turns  from  red  to  dark  blue.     Of  all  these 


EXAMINATION   OF    THE   INGESTA.  45 

colors,  I  think  Congo  red  is  the  most  reliable  one.  As 
organic  acids  when  present  in  considerable  quantity 
may  also  give  these  color  changes,  it  is  of  great  im- 
portance to  have  another  reaction  for  hydrochloric 
acid  which  the  organic  acids  do  not  show. 

Gilnzburg^s  Phloroglucin- Vanillin  Test. — Giinz- 
burg'  first  taught  us  such  a  test  with  his  phloroglucin- 
vanillin  solution.  This  solution  contains  two  parts 
phloroglucin,  one  part  vanillin,  and  thirty  parts  alco- 
hol. The  test  is  made  in  the  following  manner:  One 
drop  of  the  filtrate  is  put  on  a  porcelain  dish.  A  drop 
of  the  phloroglucin-vanillin  solution  is  added  and  well 
mixed  with  a  glass  rod.  The  porcelain  dish  is  now 
heated  over  a  spirit  lamp  and  the  fluid  allowed  to 
evaporate  slowly.  The  presence  of  even  small  quan- 
tities of  hydrochloric  acid  gives  rise  to  a  beautiful 
cherry -red  color.  If  there  be  only  traces  of  free  hydro- 
chloric acid,  the  margin  of  the  examined  spot  turns 
cherry  red. 

Boas'' "  Besorcin  Sugar  Test. — The  solution  consists 
of  resorcin  5.0,  sach.  albi  3.0,  alcohol  ad  100.  The 
test  is  made  exactly  in  the  same  way  as  with  the 
phloroglucin-vanillin  solution.  The  hydrochloric  acid 
is  recognized  by  giving  a  cherry -red  color  with  the 
Boas  reagent.  This  test  is  also  very  reliable,  but,  as 
I*  have  shown,  less  sensitive  than  the  Giinzburg  re- 
action. 

'  Giinzburg :  "  Neue  Methode  zum  Nachweis  f reier  Salzsaure  im 
Mageninhalt."     Centralblatt  f .  klin.  Medicin,  1887,  No.  40. 

2  J.  Boas  :  "  Ein  neues  Reagens  f iir  den  Nachweis  freier  Salz- 
saure im  Mageninhalt."     Centralbl.  f.  klin.  Medicin,  1888,  No.  45. 

^Max  Einhorn :  "Die  neueren  Methoden  der  Magenunter- 
suchung.-'     New  Yorker  medicinische  Monatschrift,  Marz,  1889. 


46  DISEASES   OF   THE   STOMACH. 

3.  Lactic  Acid. 

Uffelmann^s  Test. — The  best  test  for  lactic  acid  is 
made  with  the  Uffelmann'  solution,  which  has  always 
to  be  freshly  prepared  before  use.  It  consists  of  a  two- 
per-cent.  carbolic-acid  solution  in  water,  to  which  is 
added  a  drop  of  sesquichloride  of  iron.  This  test  solu- 
tion has  an  amethyst-blue  color.  Place  about  2  c.c. 
of  this  Uffelmann  solution  in  a  test  tube,  and  add  a  few 
drops  of  the  filtrate.  The  presence  of  lactic  acid  brings 
on  a  canary -yellow  color;  the  presence  of  fatty  acids 
produces  an  ashy-gray  color,  whereas  inorganic  acids 
decolorize  the  blue  color  of  the  Uffelmann  solution. 

As  some  phosphates  are  liable  to  give  the  same  re- 
action with  the  Uffelmann  solution  as  lactic  acid,  and 
as  these  salts  are  very  often  present  in  the  gastric  con- 
tents, the  surest  way  to  discover  the  presence  of  lactic 
acid  in  the  filtrate  is  the  following:  5  or  10  c.c.  of 
the  filtrate  are  well  shaken  for  quite  a  while  in  a  test 
tube  with  a  double  quantity  of  ether.  Then  the  tube 
is  allowed  to  stand  a  few  minutes  until  the  ether  has 
separated  from  the  watery  solution.  Pour  the  ethereal 
portion  into  another  test  tube,  which  is  placed  in  a 
glass  of  hot  water,  so  as  to  allow  its  contents  to  evajD- 
orate.  After  evaporation  has  taken  place,  only  a  few 
drops  remain  in  the  test  tube.  Add  1  to  2  c.c.  of  dis- 
tilled water  and  test  for  lactic  acid  with  the  Uffelmann 
solution.  If  a  canary-3''ellow  color  now  arises,  the 
presence  of  lactic  acid  is  positively  shown. 

Instead  of  evaporating  the  ether  Fleischer'  recom- 

'  Uffelmann  :  Deutsches  Archiv  f.  klin.  Med.,  toI.  26,  p.  481. 
'Fleischer:    "Milchsaurenachweis  ini  directen  Aether. "     Cited 
from  Penzoldt :  Deutsch.  Arch.  f.  klin.  Medicin,  Bd.  li.,  p.  544. 


EXAMIXATIOX    OF    THE    IXGESTA.  47 

mends  testing  the  poured  off  ethereal  extract  directly 
with  the  Uffelmann  solution ;  the  presence  of  lactic 
acid  gives  the  canary-yellow  color  above  described. 

Boas^  Procediu^e  for  the  Qualitative  Determination 
of  Lactic  Acid. — The  principle  of  this  method  con- 
sists in  the  fact  that  when  solutions  of  lactic  acid  are 
treated  and  heated  with  oxidizable  substances,  a  split- 
ting of  these  occurs  into  acetaldehyde  and  formic 
acid,  according  to  the  following  formula: 

CH3  -  CH  (OH)  -  COOH  =  CH3  -  CHO  -  CHOOH. 
Lactic  acid  Acetaldehyde  Formic  acid. 

The  method  of  procedure  is  as  follows:  Take  10-20 
c.c.  of  the  filtrate  and  evaporate  in  a  porcelain  dish 
over  the  water-bath  to  a  syrupy  consistence.  (If  hy- 
drochloric acid  was  present,  then  the  addition  of 
barium  carbonate  during  the  evaporation  is  neces- 
sary.) Add  a  few  drops  of  phosphoric  acid,  expel  the 
carbonic  acid  by  boiling,  and  after  cooling,  extract 
with  small  portions  of  ether  (two  or  three  times,  50 
c.c.  each).  After  stirring  for  half  an  hour  pour  off 
the  clear  layer  of  ether.  The  ether  is  now  evaporated ; 
the  residue,  taken  up  witb  ■±5  c.c.  of  water,  is  well 
shaken  and  filtered.  To  the  filtrate  add  5  c.c.  of  con- 
centrated sulfihuric  acid  (sp.  gr.  1.89)  and  a  knife- 
pointful  of  manganese.  The  mixture  is  now  distilled 
and  the  vapors  conducted  into  a  cylinder  which  con- 
tains either  o-lO  c.c.  of  an  alkaline  solution  of  iodine 
{i.e.,  equal  parts  of  decinormal  iodine  solution  and 
standard  potassium -hydrate  solution),  or  the  same 
quantity  of  Xessler's  reagent.  If  lactic  acid  is  pres- 
ent, the  aldehyde  escapes  with  the  vapors  and  gives 


48  DISEASES   OF   THE   STOMACH. 

rise  to  the  formation  of  iodoform  (turbidity  and  iodo- 
form smell,  Lieben's  reaction),  or  (with  Nessler's  rea- 
gent) of  the  yellowish-red  aldehyde  of  mercury  as 
shown  by  the  yellow  color. 

On  the  same  principle,  Boas  also  devised  a  quantita- 
tive method  for  determining  the  amount  of  lactic  acid. 
This  new  test  has  certainly  a  scientific  value,  but  thus 
far  it  has  remained  without  practical  imjDortance. 
The  procedure  is  quite  complicated  and  hardly  gives 
more  accurate  results  than  the  usual  test  of  Uff  elmann 
described  above. 

^.  Acidity. 

The  degree  of  acidity  is  examined  by  adding  a  drop 
of  a  one-per-cent.  alcoholic  solution  of  phenol jDhthalein 
to  10  c.c.  of  the  filtrate  and  adding  again  as  many 
cubic  centimetres  of  a  one-tenth  normal  sodium -hydrate 
solution  until  a  slightly  red  color  arises.  The  amount 
of  cubic  centimetres  of  the  one-tenth  sodium -hydrate 
solution  required  for  that  purpose  is  multiplied  by  ten 
and  expressed  with  this  figure — i.e.,  the  degree  of 
acidity  is  expressed  by  the  number  of  cubic  centimetres 
of  a  one-tenth  normal  sodium-hydrate  solution  re- 
quired to  saturate  or  make  slightly  alkaline  100  c.c.  of 
the  filtrate.  Thus  if  we  find  that  10  c.c.  of  the  filtrate 
require  6  c.c.  of  the  one-tenth  normal  sodium-hydrate 
solution  in  order  to  bring  on  the  red  color  after  the 
addition  of  phenolphthalein,  we  say  the  acidity  is  60. 
The  figure  of  acidity  multiplied  by  0.00365  gives  the 
percentage  amount  of  hydrochloric  acid.  If,  for  in- 
stance, the  acidity  is  60,  then  the  percentage  of  hydro- 
chloric acid  will  be  60X0.00365  =  0.219  per  cent. 


EXAMINATION   OP   THE   IXGESTA.  49 

Tne  different  elements  comprising  the  acidity,  and 
their  quantitative  determination,  we  shall  describe 
later  on. 

5.  Propeptone. 

The  digestive  action  of  the  stomach  results  in  the 
formation  of  propeptones  and  peptones  from  the  al- 
buminates. The  best  test  for  the  presence  of  propep- 
tone is  the  addition  of  an  equal  part  of  a  saturated 
solution  of  sodium  chloride  to  a  small  quantity  of  the 
filtrate.  Propeptone  then,  if  present,  is  precipitated, 
and  the  solution  becomes  the  more  turbid  the  greater 
the  quantity  of  propeptone.  In  case  no  precipitate  is 
formed,  add  a  drojD  or  two  of  acetic  acid,  then  the 
solution  will  turn  turbid  in  case  propeptone  is  present. 
If  heated  the  solution  clears  up  again,  and  when 
allowed  to  cool  the  projDeptone  precipitates  anew,  and 
the  solution  again  turns  turbid. 

6.  Peptone. 

A  few  cubic  centimetres  of  the  filtrate  (best  after 
having  precipitated  the  propeptone  and  filtered)  are 
made  strongly  alkaline  by  the  addition  of  some  sodium - 
hydrate  solution  and  a  few  drops  of  a  weak  (one-per- 
cent) sulphate-of -copper  solution  added.  The  presence 
of  peptone  gives  rise  to  a  purplish  or  violet-red  color 
(biuret  reaction). 

7.  Pepsin. 

A  thin  disc  (1  cm.  in  diameter  and  about  1  mm. 
thick)  of  the  white  of  a  hard-boiled  egg  is  put  into  a 
test  tube  containing  5  c.c.  of  the  filtrate  and  kept 
at   blood   temperature.     If   hydrochloric   acid    is   not 


50  DISEASES    OF   THE    STOMACH. 

jDresent  in  the  filtrate,  it  is  necessary  to  add  two  drops 
of  the  dilute  muriatic  acid.  The  presence  of  pepsin 
effects  a  disintegration  or  a  disappearance  of  the  egg 
disc  in  two  to  six  hours. 

S.  Bennet  Ferment. 
Take  about  5  c.c.  of  milk  in  a  test  tube  and  add 
three  to  four  drops  of  the  filtrate.  Mix  thoroughly 
and  keep  the  tube  in  a  glass  of  warm  water.  In 
about  ten  to  fifteen  minutes  the  milk  becomes  curdled. 
In  case  coagulation  does  not  occur  in  an  hour  or  two, 
then  no  rennet  ferment  is  present,  although  rennet 
zymogen  may  exist.  To  test  for  the  latter,  it  is 
necessary  to  add  to  the  same  specimen  of  milk  a  few 
drops  of  a  oue-per-cent  chloride -of- calcium  solution, 
and  again  allow  it  to  stand  a  few  minutes.  If  the 
milk  remains  uncurdled  even  then,  there  was  no  ren- 
net zymogen  present,  otherwise  the  coagulation  would 
have  taken  place. 

9-12.  Tlw  Products  of  Starch  Digestion. 
The  starchy  derivatives  resulting  from  the  action 
of  the  ptyalin-digestion  begun  in  the  mouth  and  con- 
tinued in  the  stomach,  consist  of  erythrodextrin,  ach- 
roodextrin,  and  maltose.  A  few  drops  of  Lugol's 
solution  (iod.  0.1,  potass,  iod.  0.2,  aq.  dest.  200.0) 
are  added  to  a  small  quantit}^  of  the  filtrate.  The 
presence  of  (9)  dextrin  turns  the  fluid  blue;  (10)  ery- 
throdextrin gives  rise  to  a  red  color.  The  (11)  achroo- 
dextrin  discolors  the  yellowish  tint  of  the  Lugol  solu- 
ion,  while  (12)  maltose  does  not  change  the  color  of 
the  solution.  For  maltose  or  sugar,  we  can  besides 
make  use  of  Trommer's  test. 


EXAMINATION   OF   THE    INGESTA.  51 

In  the  healthy  condition,  the  results  of  the  analysis 
of  the  stomach  contents  one  to  one  and  a  half  hours 
after  the  test  breakfast  are  as  follows :  acid  reaction ; 
free  hydrochloric  acid  present ;  lactic  acid  not  present ; 
total  acidity  varying  from  40-60  (=0.015-0.21  per  cent 
hydrochloric  acid) ;  propeptone  present  in  small 
amount;  peptone  in  larger  proportions;  pepsin  and 
rennet  present ;  sugar  present ;  achroodextrin  present; 
erythrodextrin  present  in  small  amounts  or  absent; 
dextrin  absent.  From  these  normal  standards  we  find 
many  deviations  in  the  sick,  and  we  shall  have  to  in- 
vestigate later  on  the  chemical  processes  in  the 
stomach  in  all  disturbances  of  this  organ. 

Although  the  above  tests  will  suffice  for  the  great 
majority  of  cases,  we  find  it  necessary  to  give  a  few  ad- 
ditional methods  which  are  not  complicated  and  which 
will  serve  to  determine  several  factors  in  the  gastric 
analysis  more  minutely.  The  acidity  of  the  gastric 
contents  is  as  a  rule  due  to  acid  salts,  acid  compounds 
of  albumin,  and  free  acids  (hydrochloric  and  lactic, 
and  sometimes  various  organic  acids).  It  is  some- 
times of  importance  to  ascertain  the  presence,  respec- 
tively the  quantity,  of  each  of  these  factors  sep- 
arately. 

Volatile  Acids. 

The  presence  of  fatty  or  volatile  acids  is  recognized 
by  boiling  a  few  cubic  centimetres  of  the  filtrate  in  a 
test  tube.  A  strip  of  wet,  blue  litmus  paper  is  held 
over  the  vapors  escaping  at  the  top  of  the  test  tube. 
Their  presence  will  turn  blue  litmus  paper  red.  The 
quantity  of  these  fatty  acids  can  be  ascertained  by 
boiling  10  CO.  of  the  filtrate  for  about  half  an  hour, 


52  DISEASES  OF   THE   STOMACH. 

adding  to  the  residue  sufficient  distilled  water  until 
the  quantity  araounts  again  to  10  c.c,  and  now  de- 
termining the  degree  of  acidity  in  this  liquid  by  phenol- 
phthalein  and  sodium  hydrate.  This  figure  sub- 
tracted from  the  figure  of  the  total  acidity  of  the  fil- 
trate will  give  the  quantity  of  the  fatty  acids. 

Acetic  Acid. 
Acetic  acid  if  present  in  larger  quantities  can  easily 
be  detected  by  its  characteristic  smell;  if  present  in 
smaller  quantities  it  may  be  detected  by  neutralizing 
the  watery  residue  of  the  ethereal  extract  with  carbon- 
ate of  soda,  and  then  adding  neutral  chloride-of-iron 
solution,  when  a  beautiful  red  color  is  developed. 

Estimation  of  Lactic  Acid. 

The  quantitative  determination  of  lactic  acid  may  be 
made  in  the  following  way:  10  c.c.  of  the  filtrate 
are  well  shaken  with  a  larger  quantity  of  ether.  The 
ether  is  then  separated  from  the  watery  solution  and 
the  degree  of  acidity  determined  in  this.  By  subtract- 
ing the  figure  thus  obtained  from  the  total  acidity  and 
multiplying  by  0.09,  we  have  the  percentage  of  lactic 
acid.  This  method  presupposes  the  absence  of  vola- 
tile acids:  if  they  are  present,  they  have  to  be  first 
eliminated  by  boiling.  The  further  steps  in  the  proc- 
ess of  determining  the  quantity  of  lactic  acid  will 
then  be  performed  in  the  way  described. 

Estimation  of  Free  Hydrochloric  Acid. 

This  can  be  done  by  any  one  of  the  following 
methods: 


EXAMINATION   OF    THE   INGESTA.  53 

1.  Mintz's'  Method.— Ho  10  c.c.  of  the  filtrate  de- 
cinormal  sodium  hydrate  is  added  in  such  a  quantity 
that  a  drop  of  the  mixture  no  longer  responds  to  Giinz- 
burg's  phloroglucin-vanillin  test.  The  amount  of  the 
decinormal  soda  solution  used  multiplied  by  ten  gives 
the  figure  of  the  free  hydrochloric  acid.  The  per- 
centage of  free  hydrochloric  acid  can  be  obtained  from 
this  figure  in  the  same  manner  as  above  stated  for  the 
total  acidity,  by  multi^Dlying  it  by  0.00365. 

2.  Method  of  Moerner^  and  Boas.^ — The  degree  of 
acidity  of  free  hydrochloric  acid  is  here  determined 
either  by  Congo  paper  or  by  a  one-per-cent  solution  of 
Congo  red  as  an  indicator  v^hich  turns  blue  in  the  pres- 
ence of  the  acid.  The  decinormal  soda  solution  is  then 
added  until  the  blue  color  begins  to  turn  red.  Boas 
takes  5  c.c.  of  the  filtrate  and  5  c.c.  of  the  watery 
Congo-red  solution  (one  per  cent).  I  myself  add  only 
one  or  two  drops  of  the  same  solution  to  the  filtrate. 
The  estimation  is  done  in  the  same  way  as  before. 

3.  Toejpfer^s*  Method. — Toepfer  makes  use  of  dime- 
thylamido-azobenzol  in  a  half-per-cent  alcoholic  solu- 
tion for  the  recognition  and  the  estimation  of  the 
amount  of  free  hydrochloric  acid.  Hydrochloric  acid 
even  in  small  quantities  gives  a  red  color  with  this  in- 
dicator. The  decinormal  solution  of  sodium  hydrate 
is  added  until  the  red  color  disappears;  a  faint  yellow 
color    arises.       This    method    has    been    thoroughly 

'  S.  Mintz  :  "Eine  einfache  Methode  zur  quantitativen  Bestim- 
murig  der  f reien  Salzsaure  im  Mageninhalt. "  Wiener  klin.  Woch- 
enschr.,  1889,  No.  20. 

'  Moerner :  Maly's  Jahresbuch  f.  Thierchemie,  vol.  19,  p.  253. 

3 Boas:  Ceotralbl.  f.  klin.  Medicin,  1891,  No.  2. 

■*  G.  Toepfer :  Zeitschr.  f.  physiolog.  Chemie,  Bd.  19,  Heft  i.,. 
1894. 


54  DISEASES   OF   THE   STOMACH. 

studied  in  this  country  by  J.  Friedenwald  '  and  highly 
recommended. 

From  m}'  own  experience  I  would  recommend  this 
method  for  the  quantitative  determination  of  free 
hydrochloric  acid,  when  the  presence  of  the  latter  has 
been  first  demonstrated  byGiinzburg's  test;  for  lactic 
acid,  if  present  in  considerable  quantity,  may  also 
give  a  positive  reaction  with  Toepfer's  solution. 

In  a  paper  on  this  subject "  which  I  published  very 
recently  it  can  be  easily  seen  that  lactic  acid,  if  alone 
present,  responds  to  Toepfer's  test  even  if  it  exists  in 
a  percentage  above  0.1,  and  in  gastric  contents  if 
present  in  a  percentage  of  0.2, 

Estimation  of  Combined  Hydrochloric  Acid. 

The  combined  hydrochloric  acid  may  be  determined 
according  to  Toepfer  by  titrating  with  alizarin  until 
the  appearance  of  a  violet  color,  and  deducting  the 
found  acidity  from  the  total  acidity  with  phenol- 
phthalein  as  an  indicator.  Toepfer  asserts  that  aliz- 
arin is  sensitive  for  all  the  elements  comprising  the 
acidity  except  for  the  combined  hydrochloric  acid. 

In  case  free  hydrochloric  acid  is  absent,  and  it  should 
be  important  to  ascertain  whether  combined  hydro- 
chloric acid  is  present,  the  following  method  suggested 
by  Sjoequist '  and  modified  by  Ewald  '  may  be  applied: 
10  c.c.  of  the  filtrate  are  mixed  with  about  one-half 

'  J.  Friedenwald  :  Medical  Record,  April  6th,  1895. 

2  Max  Einhorn:  "The  Dimethylamido-azobenzol  or  Toepfer's 
Test  for  Free  Hydrochloric  Acid.  "  New  York  Medical  Journal, 
May  9th,  1896. 

3 Sjoequist:  Zeitschr.  f.  physiolog.  Chemie,  1887,  vol.  13,  Heft 
1-2,  p.  1. 

*C.  A.  Ewald  :  "Diseases  of  the  Stomach,"  p.  39. 


EXAMINATION    OF    THE    INGEST  A.  55 

gram  barium  carbonate  in  a  platinum  capsule.  The 
fluid  IS  then  evaporated  to  dryness  and  reduced  to 
ashes.  After  cooling,  the  residue  is  dissolved  in  hot 
water  and  filtered.  Several  drops  of  a  concentrated 
soda  solution  are  now  added  to  the  filtrate.  If  the 
fluid  remains  clear,  hydrochloric  acid  is  totally  absent. 
If  a  precipitate  forms  after  the  addition  of  the  soda 
solution,  then  the  amount  of  this  precipitate  will  allow 
us  to  judge  approximately  of  the  quantity  of  com- 
bined hydrochloric  acid. 

Estimation  of  Acid  Salts. 

Leo'S  Jlethod. — The  presence  as  well  as  the  quan- 
tity of  acid  salts  is  best  determined  by  Leo's'  method. 
A  few  drops  of  the  filtrate  are  put  in  a  watch  glass 
and  a  small  amount  of  powdered,  chemically  pure  cal- 
cium carbonate  is  added,  stirred  with  a  glass  rod,  and 
the  reaction  tested  with  blue  litmus  paper.  If  it 
turns  red,  then  acid  salts  are  present,  for  the  calcium 
carbonate  combines  only  with  the  free  acids  but  not 
with  the  acid  salts. 

Leo's  method  for  determining  the  quantity  of  free 
and  combined  acid  is  based  on  the  principle  that  cal- 
cium carbonate  neutralizes  free  and  combined  hydro- 
chloric acid,  but  not  the  acid  salts  at  ordinary  temper- 
atures. As  the  degree  of  acidity  of  acid  phosphates 
is  larger  when  calcium  chloride  is  present,  and  inas- 
much as  this  salt  is  always  developed  in  small  quan- 
tities after  the  addition  of  calcium  carbonate,  Leo  de- 
termines the  acidity  before  and  after  the  addition  of 
the  latter,  having  added  calcium  chloride  to  both. 
One  proceeds  as  follows : 

'Leo:  "'Eine  neue  Methode  zur  Saurebestimmung  im  Magen- 
inlialt."     Centralbl.  f.  die  med.  Wissenschaft.  1889,  No.  26. 


56  DISEASES   OP   THE   STOMACH. 

After  the  separation  of  all  organic  acids  from  the 
filtrate,  10  c.c.  (first  portion)  are  taken,  and  5  c.c.  of  a 
concentrated  calcium -chloride  solution  added  and  the 
degree  of  acidity  is  determined  by  phenolphthalein 
and  a  decinormal  sodium-hydrate  solution. 

Fifteen  cubic  centimetres  of  the  filtrate  of  the  gastric 
contents  (second  portion)  are  again  taken  and  mixed 
with  powdered,  chemically  pure  calcium  carbonate  and 
filtered.  Of  this  filtrate  10  c.c.  are  taken  and  placed 
in  a  bottle  provided  with  a  rubber  stopper  in  which 
are  inserted  two  glass  tubes,  one  short  and  the  other 
reaching  down  nearly  to  the  bottom  of  the  bottle.  To 
the  upper  end  of  this  long  glass  tube  is  attached  a 
piece  of  rubber  tubing  terminating  in  a  bulb,  by  means 
of  which  air  can  be  introduced  into  the  bottle.  After 
the  air  has  been  blown  in  for  some  time,  in  order  to 
drive  out  the  carbonic  acid  that  has  formed,  the  acid- 
ity of  the  solution  is  determined  with  phenolphthalein 
and  decinormal  sodium -hydrate  solution.  By  sub- 
tracting the  figure  of  acidity  obtained  from  the  second 
portion  from  that  obtained  from  the  first,  we  have  the 
amount  of  acidity  corresponding  to  the  free  and  com- 
bined hydrochloric  acid. 

If  no  organic  acids  have  been  present  in  the  filtrate, 
the  last-obtained  figure,  subtracted  from  the  total 
acidity,  will  give  the  quantity  of  acid  salts. 

Other  More  Complicated  Methods  for  the  Determin- 
ation of  the  Quantity  of  Hydrochloric  Acid. 

Method  of  Hehner  and  Seemann.^ — 10  c.c.  of  the 
filtrate  are  neutralized  with  a  decinormal   standard 

'Seemann:  Zeitschr.  f.  klin.  Medicin,  vol.  v.,  p.  272. 


EXAMINATION   OF   THE   INGESTA.  57 

solution  of  sodium  hydrate,  evaporated  to  dryness  over 
the  water  bath,  and  calcined  over  the  flame.  The 
residue  consists  of  neutral  salts  +  carbonate  of  sodium. 
The  latter  is  determined  in  the  following  manner: 
The  residue  is  washed  with  hot  water  and  filtered  as 
long  as  the  filtrate  gives  an  alkaline  reaction.  This 
filtrate  is  then  titrated  with  a  decinormal  standard 
solution  of  sulphuric  acid,  until  a  slightly  acid  reaction 
aT^ses.  The  amount  of  the  decinormal  standard  sul- 
phuric-acid solution  used  corresponds  to  the  amount 
of  inorganic  acid.  The  difference  between  this  figure 
and  the  figure  of  the  total  acidity  expresses  the 
amount  of  free  and  combined  hydrochloric  acid. 

Method  of  Hay  em  and  Winter.^ — The  principle  of 
this  method  consists  in  the  determination,  first,  of  the 
total  amount  of  chlorides ;  second,  of  the  fixed  chlorides 
(chloride  salts);  and  third,  of  the  amount  of  chlorides 
combined  with  acids.  Proceed  as  follows :  In  each  of 
three  porcelain  dishes  (a,  6,  c)  place  5  c.c.  of  the  filtrate. 
To  dish  a  an  excess  of  carbonate  of  sodium  is  added. 
All  the  three  dishes  are  then  evaporated  to  complete 
dryness  over  a  water  bath.  A  solution  of  carbonate  of 
soda  is  now  added  in  excess  to  dish  h  and  the  contents 
are  again  evaporated  to  dryness.  All  the  three  dishes 
are  then  calcined  over  a  Bunsen  burner,  but  the  heat- 
ing should  not  be  carried  too  far,  and  the  calcination 
^hould  be  arrested  when  there  are  no  more  points  of 
ignition.  To  dishes  a  and  h  a  slight  excess  of  pure 
nitric  acid  is  added  and  then  some  distilled  water. 
After  boiling  the  contents  of  these  two  dishes  (a  and 
6),  they  are  thrown  on  a  filter.     Dish  c  is  treated  with 

■  Hayem  et  Winter :  "  Du  Chimisme  Stomachal, "  Paris,  1891,  p.  72. 


68  DISEASES  OP  THE   STOMACH. 

boiled  water  aloue  and  then  also  filtered.  The  amoutit 
of  chlorides  contained  in  the  three  different  filtrates  is 
then  determined  by  a  decinormal  standard  solution  of 
nitrate  of  silver  in  the  presence  of  yellow  chromate  of 
potassimn  as  indicator.  Dish  a  shows  the  total 
amount  of  the  chlorides  (T  =  chlore  total),  h  =  com- 
bined +  fixed  chlorine,  and  c=F  =  chlore  fixe;  h  —  c 
corresponds  to  the  amount  of  combined  hydrochloric 
acid  =  C  =  chlore  combine;  a  —  h  corresponds  to  the 
amount  of  free  hydrochloric  acid  =  H  =  free  hydro- 
chloric acid.  The  total  acidity  is  determined  by  titra- 
tion with  a  decinormal  sodium-hydrate  solution  and 
phenolphthalein  as  mentioned  above. 

Determination  of  the  Hydrochloric  Acid  Deficit. 

Honigmann  and  von  Noorden*  advised  that  the 
amount  of  combined  hydrochloric  acid  in  cases  in 
which  free  acid  is  lacking  be  determined  by  the 
amount  of  decinormal  standard  hydrochloric-acid 
solution  required,  in  order  to  give  a  positive  reaction 
for  free  hydrochloric  acid,  or  they  really  determined 
the  deficit  of  hydrochloric  acid  which  exists  in  the 
filtrate,  in  order  to  combine  with  all  the  proteids. 
The  more  of  the  decinormal  hydrochloric-acid  solu- 
tion it  is  necessary  to  add  in  order  to  give  a  positive 
reaction  for  free  acid,  the  less  the  amount  of  combined 
hydrochloric  acid  in  the  filtrate.  I  do  not  think  that 
this  procedure  is  very  important,  for  the  degree  of 
acidity  alone  already  gives  us  a  sufficient  clew  as  to 

1  Honigmann  und  von  Noordeu  ;    Zeitschrift  f.  klin.  Medicin, 
Bd.  xiii. 


EXAMINATION   OF    THE    INGESTA.  59 

this  condition.  Moreover,  the  amount  of  peptone  and 
propeptone  qualitatively  found  in  the  filtrate  will  also 
indicate  the  greater  or  smaller  amount  of  combined 
hydrochloric  acid.  If  there  is  no  combined  hydro- 
chloric acid  whatever,  then  there  will  be  no  biuret 
reaction  present. 

During  the  last  six  or  seven  years  a  host  of  methods 
have  been  described,  serving  the  purpose  of  determin- 
ing analytically  either  the  free  and  the  combined 
hydrochloric  acids  or  the  chlorides.  "We  need  only 
mention  the  methods  of  Sjoequist,*  Martins  and 
Luettke,^  and  the  above-described  procedures  of 
Hehner-Seemann'  and  Hay  em-Winter.*  All  of  these 
are  quite  complicated  and  far  from  being  exact.  It 
has  been  found  that  the  gastric  contents  include  con- 
siderable quantities  of  ammonia  (NHg)  in  the  form  of 
ammonium  chloride  (NH^Cl).  All  the  methods  men- 
tioned are  based  on  results  obtained  under  the  applica- 
tion of  heat,  notwithstanding  the  fact  that  the  latter 
will  lead  to  the  evaporation  of  ammonia  and  the  for- 
mation of  free  hydrochloric  acid.  The  error  which 
thus  arises  merely  from  this  circumstance  exceeds  ten 
per  cent  (Rosenheim,^  H.  Strauss, °  and  others).  But 
besides  the  errors  of  these  analytical  methods,  it  has 
been  found  by  the  most  eminent  authors  that  in  refer- 
ence to  treatment  and  diagnosis  we  do  not  derive  from 

'  Sjoequist :  L.  c. 

"^  Marti  us  and  Luettke  :  "Die  Magensaure  des  Menschen,"  Stutt- 
gart, 1893. 

^Seemann:  Zeitschr.  f.  klin.  Medicin,  vol.  5,  p.  272. 

^  Hayem  et  "Winter :  "  Du  Chimisme  Stomachal, "  Paris,  1891, 
p.  72. 

^Th.  Rosenheim:  Centralbl.  f.  klin.  Medicin,  1892,  No.  39. 

«H.  Strauss:  Berl.  klin.  Wochenschr.,  1893,  No.  17. 


60  DISEASES   OF   THE    STOMACH, 

these  tests  any  more  data  than  from  the  simple  method 
of  titration  and  determination  of  free  hydrochloric  acid 
(Honigmann,' Von  Xoorden,'H.  Strauss,  Eosenheim). 
For  this  reason  I  did  not  think  it  necessary  to  give 
a  detailed  account  of  all  analytical  methods.  For 
practical  purposes  the  determination  of  the  total  acid- 
ity (A  =  aciditas),  of  free  hydrochloric  acid  (L  =  acidum 
hydrochloricum  liherum),  ancl  the  qualitative  test  for 
lactic  acid  as  above  detailed  will  suffice.  In  some  in- 
stances Leo's  method  may  also  be  applied  ;  in  this  way 
the  quantity  of  combined  hydrochloric  acid  (C=acidum 
hydrochloricum  combinatum)  and  the  quantity  of  acid 
salts  may  be  ascertained. 

Co7itr a- Indications  to  the  Use  of  the  Stomach  Tube. 

The  application  of  the  tube  is  not  advisable  in  cases 
of  recent  hemorrhages,  no  matter  whether  from  the 
stomach  or  from  the  lungs,  in  all  cases  of  fresh  ulcers 
of  the  stomach,  aortic  aneurism,  and  in  markedly 
cachectic  and  debilitated  persons.  In  cases  in  which 
there  is  a  mere  suspicion  of  an  ulcer,  some  authors 
employ  the  soft-rubber  tube,  while  others  are  opposed 
to  its  application. 

Other  Methods  of  Testing  the  Gastric  Secretion. 

Notwithstanding  the  great  importance  of  the  results 
derived  from  chemical  analysis  of  the  stomach  contents 
obtained  by  means  of  the  soft-rubber  tube,  this  com- 
paratively new  method  has  not  as  yet  been  generally 

'Honigmann:  Berl.  klin.Wcchenschv. ,  1893,  Nos.  15  and  16. 
^C.  TonNoorden:  Berl.  klin.  Wochenschr..  1893,  No.  18. 


EXAMINATION   OF   THE    INGESTA.  61 

adopted  by  the  medical  profession,  for  the  reason  that 
the  examination  by  means  of  the  tube  is  often  unpleas- 
ant and  repugnant  to  the  patient.  Moreover,  some 
patients  absolutely  refuse  to  undergo  this  method  of 
examination.  To  obviate  these  difSculties  several 
other  methods  have  been  devised  : 

1.  Giinzhurg''s^  Method. — Patient  swallows  0.2  gm. 
potassium  iodide  enclosed  in  a  small  rubber  bag  fastened 
with  fibrin  threads.  After  the  disintegration  of  the 
fibrin  by  digestion,  the  rubber  bag  opens  and  the  po- 
tassium iodide  is  now  set  free  and  ready  for  absorp- 
tion. As  soon  as  iodine  is  detected  in  the  saliva,  we 
are  sure  that  the  fibrin  has  been  digested  and  from 
this  Giinzburg  concluded  the  presence  of  hydrochloric 
acid.  This  method,  though  ingenious,  is  not  adapted 
for  practical  purposes,  for  while,  on  the  one  hand,  it 
necessitates  examining  the  saliva  for  quite  a  period  of 
time  (one  to  two  hours),  on  the  other  hand  the  appear- 
ance of  iodine  in  the  saliva  does  not  conclusively  prove 
that  the  fibrin  has  been  digested  in  the  stomach.  The 
rubber  bag  may  have  escaped  into  the  intestines,  the 
fibrin  may  have  been  digested  there,  and  the  potas- 
sium iodide  absorbed.  Thus  we  cannot  reach  any  de- 
cisive conclusion  as  to  the  condition  of  gastric  secretion 
by  this  method.  The  same  remarks  apply  to  Sahli's 
method,  which  corresponds  in  most  respects  to  the  one 
just  described. 

2.  Spallanzani  and  Edinger^s  Sponge  Method. — 
Edinger^  fastened  a  small  sponge  to  a  silk  thread 
which  he  caused  his  patient  to  swallow.     After  several 

'Giinzburg:  Deutsche  med.  Wochenschr. ,  1889,  No.  41. 
^Edinger:     "Zur  Physiologie    und    Pathologie    des    Magens," 
Deutsch.  Arch.  f.  klin.  Medicin,  toI.  28,  1881. 


62  DISEASES   OF   THE   STOMACH 

minutes  he  withdrew  the  sponge  from  the  stomach, 
and  examined  the  contents  squeezed  out  for  hydro- 
chloric acid.  This  method,  which  had  heen  practised 
before  by  Spallanzani,  is  deficient  in  the  following  par- 
ticulars: 1.  The  sponge  is  jDartly  squeezed  out  during 
its  withdrawal  through  the  narrow  passages  (cardia 
and  introitus  oesophagi),  and  thus  much  of  the  gastric 
contents  obtained  is  lost.  2.  It  absorbs  some  of  the 
secretions  of  the  oesoiDhagus  and  pharynx.  Thus  the 
few  remaining  drops  of  gastric  contents  in  the  sponge 
are  impure  (that  is,  mixed  with  other  fluids)  and  some- 
times are  altered  in  their  chemical  state. 

3.  Stomach  Bucket  (Einhorn^) .  — The  bucket  consists 
of  a  small  capsule-shaped  vessel  (If  cm.  long,  f  cm. 
wide)  made  of  silver;  on  the  top  there  is  a  large 
opening  surmounted  by  an  arch  to  which  a  silk  thread 
is  tied,  and  a  knot  made  at  a  distance  of  sixteen 
inches  from  the  attachment. 

Method :  In  order  to  obtain  a  sample  of  the  stomach 
contents,  proceed  as  follows:  The  bucket  is  dipped 
into  lukewarm  water,  filled  and  emptied.  (This 
serves  to  make  the  inside  of  the  vessel  moist,  so  that 
it  will  more  easily  take  up  the  contents  of  the  stomach.) 
Then  the  patient  is  asked  to  open  his  mouth  widely, 
and  the  bucket  is  placed  on  the  root  of  the  tongue 
(almost  in  the  pharynx) ;  the  patient  should  now 
swallow  once  or  twice. 

The  vessel  after  a  short  time  (one  to  two  minutes) 
enters  the  stomach.  As  soon  as  the  knot  of  the  thread 
is  at  the  lips  the  bucket  is  in  the  stomach,  for  the  dis- 

'  Max  Einhorn  :  "A  New  Method  of  Obtaining  Small  Quantities 
of  Gastric  Contents  for  Diagnostic  Purposes. "  Medical  Record, 
July,  1890. 


EXAMINATION   OF   THE   INGESTA. 


63 


taDce  from  the  teeth  to  the  cardia  is  usually  sixteen 
inches.  The  vessel  is  left  there  for  about  five  min- 
utes and  then  withdrawn.  During  the  withdrawal 
of  the  apparatus  a  resistance  is  usually  felt  at  the 
introitus  oesophagi.  To  overcome  this  difSculty, 
when  the  apparatus  is  at  that  narr^ow  point  the  pa- 
tient should  swallow. 

By  the  act  of  swallowing  the  larynx  is  pushed  for- 


FiG.  13— The  Stomach  Bucket  (Ein- 
horn).  1,  Small  size;  8,  large 
size  ;  3,  top  view. 


Fig.  14.— The  Stomach  Bucket  Set. 


ward  and  upward,  and  thus  the  passage  is  free  and 
the  bucket  can  be  withdrawn  easily.  If  the  stomach 
is  not  empty,  the  bucket  returns  filled  and  the  amount 
is  sufficient  for  making  various  important  tests.  In 
people  suffering  from  an  abundant  secretion  of  the 
mucous  membranes  the  bucket  might  become  filled 
with  mucus  before  entering  the  stomach,  and  then  in 
emptying  the  vessel  one  would  find  clear  mucus  in- 
stead of  chyme.  In  such  cases  it  is  necessary  to  make 
the  trial  again  and  to  cover  the  opening  with  a  thin 
gelatinous  capsule,  which  keeps  away  the  mucus  from 


64  DISEASES  OF   THE   STOMACH, 

the  vessel  on  its  way  to  the  stomach ;  there  the  capsule 
is  dissolved  and  the  stomach  contents  can  now  enter 
the  apparatus.  On  its  return  from  the  stomach,  the 
bucket  being  filled,  the  mucus  cannot  to  any  extent 
enter  it.  The  best  time  for  obtaining  a  sample  of  the 
stomach  contents  is  one  hour  after  Ewald's  test 
breakfast. 

This  way  of  obtaining  a  small  quantity  of  gastric 
contents  for  examination  does  not  give  any  trouble, 
nor  does  it  cause  any  exertion  to  the  patient.  Even 
in  ulcer  of  the  stomach  there  is  no  danger  whatever 
from  hemorrhage  as  a  consequence  of  the  examination. 
For  this  reason  the  method  seems  to  be  especially 
adapted  to  all  cases  where  there  is  suspicion  of  an  ulcer 
in  the  stomach,  and  where  we  desire  to  avoid  the  tube. 
It  is  also  suitable  for  the  general  practitioner  who  does 
not  intend  to  make  an  exact  analysis  of  the  gastric 
contents,  but  who  desires  to  determine  whether  there 
exists  free  hydrochloric  acid  or  not.  The  gastric  con- 
tents withdrawn  in  the  bucket  are  examined  directly 
without  being  filtered,  in  the  following  w^ay: 

1.  By  means  of  blue  litmus  paper  it  can  be  deter- 
mined whether  the  contents  are  acid ;  if  so,  the  paper 
turns  red. 

2.  With  Congo  paper  whether  there  are  free  acids 
or  only  acid  salts.  The  presence  of  free  acids  turns 
Congo  paper  blue,  otherwise  the  Congo  color  is  not 
changed. 

3.  If  there  are  free  acids  it  is  necessary  to  find  out 
whether  there  is  hydrochloric  acid  present  or  not.  For 
this  purpose  take  one  drop  of  the  contents  and  one 
drop  of  Giinzburg's  solution  and  mix  them  thorough 


EXAMINATION   OF   THE   INGESTA.  65 

ly  in  a  white  porcelain  dish.  This  dish  is  now  heated 
over  an  alcohol  lamp;  when  the  fluid  evaporates,  a 
cherry-red  color  appears  in  the  same  spot  whenever  hy- 
drochloric acid  is  present  even  in  a  very  small  amount. 

4.  The  amount  of  hydrochloric  acid,  or  the  acidity, 
can  be  approximately  determined  by  gradually  diluting 
one  drop  of  the  contents  with  water  until  the  above- 
mentioned  GiJnzburg's  reaction  for  hydrochloric  acid 
begins  to  disappear  in  the  diluted  fluid.  Normally  the 
stomach  contents  can  be  diluted  from  eight  to  ten 
times  and  yet  will  give  the  Giinzburg  reaction.  In  this 
way^  cases  in  which  we  are  able  to  dilute  only  five  times, 
or  even  less,  must  be  considered  as  cases  of  subacidity 
(too  small  amount  of  acidity),  and  cases  in  which  we 
are  able  to  dilute  more  than  twelve  times  as  cases  of 
hyperacidity  or  superacidity  (too  large  amount  of 
acidity).  In  cases  in  which  no  acidity  whatever  is 
found,  we  have  to  deal  with  anacidity. 

5.  Pepsin  and  rennet,  the  two  ferm,ents  of  the 
stomach,  generally  accompany  each  other,  and  we  can 
deduce  the  presence  of  one  from  that  of  the  other. 
We  prove  the  presence  of  the  ferments  by  making  the 
following  test  for  the  rennet  ferment :  Two  drops  of 
the  stomach  contents  are  mixed  with  about  2  c.c. 
of  milk  and  kept  either  in  a  warm  place  or  in  a  glass 
with  warm  water.  The  presence  of  rennet  curdles  the 
milk  in  from  ten  to  twenty  minutes. 

Dr.  Dickinson,'  of  Erie,  Pa.,  has  made  a  comparative 
study  of  the  results  obtained  after  an  examination  by 

^  Dickinson  :  "  A  Comparative  Study  between  the  Results  Ob- 
tained by  Examination  of  the  Stomach  Contents  by  Means  of  a 
Stomach  Tube  and  Einhorn's  Stomach  Bucket. "  Medical  Record, 
September  15th,  1894. 


66  DISEASES   OF   THE   STOMACH. 

means  of  the  tube  and  a  minute  analysis  of  the  fil- 
tered gastric  contents,  and  the  result  gained  after  ex- 
amination with  a  stomach  bucket  and  the  coarse 
method  of  analysis  just  described.  He  examined  thir- 
teen persons  by  means  of  both  methods,  and  found 
that  the  results  harmonized  pretty  closely.  The  de- 
gree of  acidity  corresiDonded  quite  accurately  to  the 
figure  obtained  by  dilution. 

The  examination  with  the  tube  is  as  a  rule  prefer- 
able to  that  with  the  stomach  bucket,  as  the  quantity 
of  gastric  contents  obtained  with  the  former  is  cer- 
tainly larger,  and  permits  a  more  detailed  examina- 
tion. Wherever,  however,  the  examination  with  the 
tube  is  either  contraindicated,  or  where  the  patients 
refuse  its  introduction,  the  examination  with  the 
bucket  will  certainly  be  able  to  replace  the  tube  and 
afford  us  more  thorough  information  as  to  the  se- 
cretory functions  of  the  stomach. 

Exact    Determination   of  the    Quantity    of    Chyme 
within  the  Stomach. 

The  quantity  of  chyme  can,  as  a  rule,  be  determined 
by  having  the  patient  empty  the  contents  of  his  stom- 
ach through  the  tube  by  means  of  the  expression 
method.  The  quantity  can  then  be  directly  measured, 
and  will  give  the  exact  figure  of  the  gastric  contents, 
provided  we  are  positive  that  the  stomach  is  now 
empty.  This  may  be  determined  by  blowing  air 
through  the  same  tube  into  the  stomach ;  if  no  bub- 
bling sound  is  heard,  but  merely  the  sound  produced 
by  the    air  on    striking  the  gastric  walls,   the  orgaii 


EXAMINATION   OF   THE   INGESTA.  67 

may  be  regarded  as  empty.  Occasionally,  however, 
it  is  quite  difficult  to  withdraw  the  eutire  quantity  of 
gastric  contents  (especially  in  cases  of  dilatation  of  the 
stomach  with  stenosis  of  the  pylorus).  In  the  latter 
instance,  the  quantity  of  the  gastric  contents  can  he 
ascertained  by  the  procedure  described  by  Mathieu  and 
Eemond.'  This  is  done  in  the  following  manner: 
Some  time  after  a  meal  a  small  portion  of  the  contents 
is  obtained  by  the  ordinary  expression  method.  Then 
the  tube,  while  still  within  the  stomach,  is  attached  to 
the  funnel  arrangement  (ordinarily  used  for  lavage) 
and  a  certain  quantity  of  water  (usually  200  c.c.) 
poured  into  the  stomach.  By  moving  the  funnel  up 
and  down  several  times  and  by  having  the  patient 
shake  his  abdomen  thoroughly,  a  complete  mixture  of 
the  ingested  water  with  the  contents  is  soon  accom- 
plished. Another  portion  of  the  mixed  gastric  con- 
tents is  now  obtained.  By  determining  the  degree  of 
acidity  in  the  first  and  second  portions  separately,  the 
amount  of  the  original  quantity  within  the  stomach 
can  be  easily  found,  according  to  the  following  cal- 
culation: If  b  represents  the  undiluted  portion  with- 
drawn, a  the  acidity  of  this  liquid,  a  the  acidity  of  the 
diluted  portion,  q  the  quantity  of  water  introduced 
into  the  stomach, — the  amount  of  acid  being  the  same 
in  the  diluted  liquid  as  in  the  original  undiluted 
gastric  contents, — the  following  equation  is  obtained: 

ax  =  aq-|-ax 

which  is  equivalent  to 

aq 
a  —  a 

'  Mathieu  et  Remond  :  Soc.  de  biolog.,  8  Nov.,  1890 


68  DISEASES   OF   THE   STOMACH. 

The  quantity  of  liquid  originally  contained  in  tlie 

stomach  is  then  represented  by  the  formula : 

y  =  b  +  _M_ 
a  —  a 

or  the  quantity  of  contents  originally  in  the  stom- 
ach is  equal  to  the  number  of  cubic  centimetres  of 
water  poured  in  within  the  stomach,  multiplied  by  the 
degree  of  acidity  of  the  second  portion,  divided  by  the 
figure  resulting  by  deducting  the  degree  of  acidity  of 
the  second  portion  from  the  first,  plus  the  portion 
previously  withdrawn. 

Abnormal  Constitnents  of  the  Gastric  Contents. 

The  gastric  contents  are  sometimes  mixed  with  some 
abnormal  products,  which  may  be  of  importance  with 
regard  to  diagnosis.  They  may  contain  mucus,  bile 
and  intestinal  juice,  blood,  and  pus. 

Mucus,  if  present  in  considerable  quantity,  is  easily 
recognized.  It  usually  occujDies  the  upper  part  of  the 
fluid,  presents  a  more  watery  color,  and  can  be  partly 
lifted  from  the  surface  by  means  of  a  glass  rod  on 
account  of  its  adhesive  quality.  If  it  is  present  only 
in  small  quantities,  its  existence  in  the  gastric  filtrate 
is  best  revealed  by  adding  a  few  drops  of  dilute  acetic 
acid,  which  then  forms  a  characteristic  precipitate, 
settling  on  the  bottom  of  the  vessel. 

Bile  and  Intestinal  Juice. — Small  quantities  of  bile 
and  intestinal  juice  in  the  stomach  are  often  met  with, 
even  normally  in  examination  of  the  patient  in  the 
fasting  condition.  The  tube  probably  produces  a  slight 
regurgitation  of  the  duodenal  contents  into  the  stom- 
ach.    The  frequent  occurrence  of  considerable  quanti- 


EXAMINATION   OF   THE    INGESTA.  69 

ties  of  bile  aud  intestinal  juice  within  the  stomach  is 
always  due  to  some  abnormal  condition,  either  to  a 
relaxation  of  the  pylorus  or  to  a  stenosis  of  the  duo- 
denum, situated  below  the  mouth  of  the  bile  duct. 
The  presence  of  bile  is  easily  noticed,  either  by  its 
golden-yellow  color  or  (if  mixed  with  gastric  juice)  by 
its  more  greenish  aspect.  Whenever  there  is  doubt  as 
to  the  presence  of  bile,  the  usual  test  which  serves  for 
its  detection  in  the  urine  may  be  applied. 

The  presence  of  intestinal  juice  is  recognized  by  its 
characteristic  ferments,  amylopsin,  steapsin,  trypsin. 

1.  The  filtrate  is  mixed  with  one-j)er-cent  solu- 
tion of  carbonate  of  sodium  until  it  has  a  decided- 
ly alkaline  reaction.  A  flake  of  fibrin  is  then  added 
to  the  filtrate,  which  is  kept  in  a  warm  place  for  quite 
a  while.  The  fibrin  will  then  dissolve  by  the  action 
of  the  trypsin. 

2.  Starch  will  be  changed  into  maltose  by  the  action 
of  the  amylopsin. 

3.  To  a  small  portion  of  milk  add  a  drop  of  blue  lit- 
mus tincture  and  a  few  cubic  centimetres  of  the  neu- 
tralized filtrate  and  keep  at  blood  temperature.  The 
presence  of  steapsin  very  soon  changes  the  blue  color, 
and  the  milk  becomes  slightly  reddish  (caused  by  the 
decomposition  of  the  fat  into  the  fatty  acids  through 
the  steapsin). 

Blood. — Blood,  if  present  in  considerable  quantities 
in  the  gastric  contents,  is  very  easily  recognized. 
Fresh  blood  can  hardly  be  mistaken  for  anything  else,  if 
present  even  in  small  quantities.  The  gastric  contents 
mixed  with  blood  present  either  a  reddish  or  (if  the 
blood  is  not  fresh)  a  slightly  brov/nish  or  coffee-ground 


70  DISEASES   OP   THE   STOMACH, 

color.  Occasionally,  if  the  blood  is  present  in  large 
quantities,  the  contents  may  appear  black.  The  detec- 
tion of  blood  in  gastric  contents  which  do  not  present 
the  appearances  just  mentioned  must  be  made  in  the 
following  manner: 

1.  A  drop  of  the  contents  may  be  examined  under 
the  microscope  for  the  presence  of  red  blood  cor- 
puscles. 

2.  By  the  Spectroscope.  If  the  presence  of  fresh 
blood  is  suspected  the  filtrate  of  the  gastric  contents 
may  be  directly  examined  with  the  spectroscope. 
Blood,  if  present,  will  show  the  two  lines  of  theoxyhse- 
moglobin.  If  the  blood  is  not  fresh,  or  if  the  gastric 
contents  include  a  considerable  quantity  of  free  hydro- 
chloric acid,  then,  according  to  Weber'  and  BoaSj^'the 
ordinary  examination  with  the  spectroscope  would  not 
show  the  presence  of  blood,  as  the  hsematin  is  not 
soluble  in  the  filtrate.  H.  Weber  therefore  suggested 
the  following  procedure : 

3.  To  the  gastric  filtrate  add  a  few  cubic  centimetres 
of  concentrated  acetic  acid,  and  shake  thoroughly  with 
sulphuric  ether.  The  latter  presents  a  Tokay-wine 
color  if  hjemoglobin  or  hsematin  is  present. 

4.  Heller^s  Blood  Test.  A  small  quantity  of  the 
gastric  filtrate  in  a  test  tube  is  mixed  with  the  same 
quantity  of  normal  urine,  and  sodium-hydrate  solution 
is  added  until  a  decided  alkaline  reaction  is  obtained. 
The  tube  is  now  heated  over  the  spirit  lamp  until  it 
begins  to  boil.     The  appearance  of  a  flaky  dark-red 

'H.  Weber:  Berliner  klin.  Wochenschr.,  1893,  No.  19. 
^J.  Boas:    "Diagnostik  und  Therapie  der  Magenkrankheiten, " 
Tbeil  1,  3te  Auflage,  p.  206. 


EXA-MIXATIOX    OP   THE    IXGESTA.  ^1 

sediment  proves  blood  (the  reaction  consists  in  the 
formation  of  haematin  and  its  combination  with  the 
precipitated  phosphates). 

5.  Sdionhein-AJmen  s  Blood  Test.  An  emulsion 
of  equal  parts  of  freshly  prepared  guaiac  tincture  and 
ozonized  oil  of  turpentine  {i.e.,  old  oil  of  turpentine 
that  has  been  exposed  to  the  air)  is  poured  into  a  test 
tube  over  the  gastric  filtrate :  a  white  ring  forms  at  the 
point  where  both  mixtures  meet,  which  ring  assumes  a 
Prussian  blue  color  if  haemoglobin  is  present.  Instead 
of  ozonized  oil  of  turpentine  the  following  solution, 
which  was  proposed  by  Hiihnerfeld,  may  be  used: 

IJ  Acid,  acetic,  glacial.,  ...         ...         2 

Aq.  dest., '     .         .         .         1 

Terebinthin.  et  spirit,  vin.  rectif.,     .        .        .       aa  100 

6.  TeichmamVs  Hcemin  Test.  A  small  quantity 
of  the  gastric  contents  is  evaporated  in  a  porcelain  dish 
over  a  spirit  lamp.  A  small  part  of  the  residue  is 
placed  on  an  object-glass  and  mixed  with  a  quantity 
of  pulverized  common  table  salt.  A  drop  of  glacial 
acetic  acid  is  poured  over  it,  covered  with  a  cover- 
glass,  and  slightly  heated  over  a  spirit  lamp  until 
small  bubbles  begin  to  rise.  Another  drop  of  acetic 
acid  is  now  again  added,  and  the  specimen  examined 
under  the  microscope.  The  presence  of  haemin  crys- 
tals (rhomboid  shape  and  beautiful  reddish  color) 
proves  blood. 

T.  KorczynsM  and  Jaworski^ s '  Blood  Test.  A 
small  quantity  of  the  filtered  residue  is  placed  in  a 
small  porcelain  dish,  a  trace  of  chlorate  of  potassium 

'  Korczynski  und  Jaworski:  Deutsche  rued.  Wochenschr. ,  1887, 
Nos.  47-49,  p.  35. 


72  DISEASES   OP   THE   STOMACH. 

and  a  drop  of  concentrated  muriatic  acid  are  added,  and 
the  mixture  is  slowly  heated  over  a  spirit  lamp.  After 
all  the  chlorine  gas  has  escaped,  one  to  two  drops  of 
a  dilute  solution  of  potassium  ferrocyanide  are  added; 
a  distinctly  hlue  color  (Berlin  blue)  arises  if  blood  is 
present. 

Pus. — Pus  is  very  seldom  found  in  the  gastric  con- 
tents and  is  recognized  by  its  characteristic  appear- 
ance under  the  microscope. 


Fig.  15. — A  Specimen  of  Mucus  in  the  Gastric  Juice  obtained  from  a  Patient  in  the 
Fasting  Condition,  showing  mucous  corpuscles,  amorphous -material,  and  few  epi- 
thelial cells. 


Microscopical  Examination  of  the  Gastric  Contents. 

(a)  Gastric  Juice.  The  microscopical  examination 
of  the  gastric  secretion  found  when  fasting  shows  nor- 
mally some  epithelial  cells,  cell  nuclei,  mucous  corpus- 
cles, amorphous  material,  and  some  micro-organisms 
(see    Fig.   15).     The   occurrence  of  snail-like  cells  in 


EXAMINATION    OF    THE    INGESTA.  73 

cases  of  hyperchlorhydria  was  first  described  by  Ja- 
worski/  who  considered  them  a  great  rarity.  Boas,*  on 
the  other  hand,  is  of  the  opinion  that  they  are  of  fre- 
quent occurrence.  The  latter  writer  considered  them 
as  substances  which  have  developed  from  the  mucus 
under  the  influence  of  the  gastric  juice.  I  concur  with 
Boas  in  his  statement  that  the  snails  are  frequently 
found,  and  would  like  to  add  that  they  may  also  be 


Fig.  16.— a  Specimeu  of  Mucus  in  tbe  Gastric  Juice  obtained  from  a  Patient  in  the 
Fasting  Condition,  showing  single  snail  forms  and  some  lying  in  groups  ;  also  amor- 
phous  material  and  few  epithelial  cells. 

found  in  patients  not  troubled  with  hyperchlorhydria. 
I  found  them  once  in  a  patient  with  normal  secretion, 
and  once  in  some  fluid  which  had  been  obtained  from 
the  oesophagus  of  a  patient  troubled  with  cancer  of 
the  cardia.  The  snails  may  lie  separately  or  in  groups 
(see  Fig.  16). 

(b)   Gastric  Contents.     The  microscopical  examina- 
tion of  the  gastric  contents  at  the  height  of  digestion 

'Jaworski:  Miincliener  med.  Wochenschr. ,  1887,  No.  32. 
^  J.   Boas :   "  Diagnostik   unci   Therap.    der  Magenkrankheiten, " 
Theil  i.,  3te  Auflage,  p.  212. 


74 


DISEASES   OF   THE   STOMACH. 


(either  one  to  one  and  a  half  hours  after  a  test  break- 
fast or  three  to  four  hours  after  a  test  dinner)  will 
allow  us  to  judge  to  a  certain  extent  regarding  the  way 
the  act  of  digestion  has  progressed.  Normally  only  a 
few  starchy  granules  are  found,  most  of  w^hich  have 
already  lost  their  characteristic  spiral  configuration. 
The  muscular  fibres  have  likewise  already  undergone 
deep  changes  and  do  not  show  diagonal  stripes.     Plant 


Fig.  1~.— a  Specimen  of  Gastric  Conteuis  in  the  Fasting  Condition  from  Patient  K., 
with  Carcinoma  Ventriculi.  a  and  6,  Partly  digested  muscle  fibres  ;  c,  starch 
granules  ;  d,  fat  globules  ;  e,  yeast  cells  ;  /,  sarcinae. 


cells,  fat  in  fine  globules,  and  different  kinds  of  micro- 
organisms are  found  in  small  numbers.  The  pres- 
ence of  a  large  amount  of  unchanged  starchy  granules 
is  most  frequently  found  in  cases  of  hyperchlorhydria, 
while  unchanged  muscle  fibres,  showing  the  diagonal 
stripes  clearly,  are  found  in  cases  with  a  diminished 
gastric  secretion.  The  different  varieties  of  micro-or- 
ganisms found  in  the  stomach  have  been  thoroughly 


EXAMINATION    OF    THE    INGESTA.  75 

studied  by  De  Bary/  Miller/  Macfadyen/  Nencki," 
Abelous, '  Boas, '  and  others.  While  a  few  years  ago  it 
was  believed  that  no  micro-organisms  can  develop  in 
the  stomach  containing  free  hydrochloric  acid  in  its 
juice,  of  late  it  has  been  proven  by  several  authors  that 
micro-organisms  may  thrive  in  the  stomach  even  if  it 
contains  too  large  a  quantity  of  hydrochloric  acid — or, 
in  other  words,  the  hydrochloric  acid  (of  the  gastric 


Fig.  18.— a  Specimen  of  Gastric  Contents  from  Patient  with  Ischochymia,  showing 
sarctnse,  yeast  cells,  fat  globules,  and  fat  crystals. 

juice)  does  not  always  exclude  fermentative  processes 
in  the  stomach.  Thus  Kaufmann,'  of  New  York, 
has  described  a  case  in  which  a  condition  of  hyper- 
chlorhydria  existed  and  in  which  the  motor  function  of 

1  De  Baiy  :  Arch.  f.  «xper.  Path,  und  Therap.,  Bd.  20,  p.  243. 

2  Miller :  "  Die  Mikro-organismen  der  Mundhohle, "  Leipzig,  1892. 
^Macfadyen:  Journal  of  Anat.  and  Physiol. ,  vol.  21,  1887. 
^Macfadyen,  Nencki,  und  Sieber  :  Arch,  f .  exper.  Patholog. ,  Bd. 

28. 

5  Abelous  :  These  de  Montpellier,  1888. 

^  Boas  :  Deutsche  med.  Wochenschr. ,  1892. 

'  J.  Kaufmann :  Berl.  klin.  Wochenschr. ,  1895,  No.  6. 


76  DISEASES   OF   THE   STOMACH. 

the  stomach  was  not  markedly  disturbed,  but  which 
notwithstanding  microscopically  gave  all  symptoms 
of  fermentative  processes.  The  gastric  contents  al- 
ways contained  numerous  living  bacteria  of  various 
types.  Dr.  Kaufmann  succeeded  in  separating  the 
eight  following  micro-organisms  from  one  specimen  of 
the  gastric  contents  by  means  of  culture:  (1)  Yellow 
sarcinae;  (2)  white  yeast;  (3)  Micrococcus  aurantiacus 


Fig.  19.  —A  Specimen  of  Gasti-ic  Conteuts  One  Hour  after  Test  Breakfast  (Patient 
with  Hyperchlorhydria),  sbowing  many  unchanged  starch  granules,  yeast  cells, 
and  a  great  number  of  micro-organisms. 

(Cohen) ;  (4)  Staphylococcus  cereus  albus  (Passet) ;  (5) 
Bacillus  subtilis;  (6)  Bacillus  ramosus;  (7)  a  large, 
thick  bacillus;  (8)  a  short  bacillus,  resembling  the 
Bacillus  coli  communis. 

Boas  has  observed  several  cases  in  which,  notwith- 
standing the  presence  of  hyperchlorhydria,  there  was 
a  decomposition  of  the  albuminate  of  the  food,  result- 
ing in  the  development  of  sulphuretted  hydrogen.  I 
have  lately  observed  two  cases  of  this  nature  myself. 


EXAMINATION   OF   THE   INGESTA,  T? 

In  cases  with  abnormal  fermentative  processes  within 
the  stomach,  the  same  kinds  of  micro-organisms  are 
usually  found  as  in  the  normal  stomach,  only  in  much 
larger  number  (Minkowski).'  Yeast  cells  and  sarcinse 
occur  in  large  numbers  in  cases  with  a  distinct  motor 
disturbance  of  the  stomach  (especially  ischochymia). 
The  sarcinse  ventriculi,  which  were  first  described  by 
Goodsir'^  in  1842,  occur  in  cubes  or  tetrahedrons  (see 


Fig.  20. — A  Specimen  of  Mucus  from  the  (Esophagus  (from  a  Patient  with  Carcinoma 
Cardies,  J.  C.  W.),  showing  mucus,  bacteria,  fat  and  epithelial  cells,  some  of  the 
latter  grouped  together. 

Fig.  lY  and  IS),  but  they  have  only  a, pathognomonic 
significance  if  they  appear  in  very  large  numbers. 

(c)  Small  pieces  of  gastric  mucosa.  In  washing  out 
the  stomach  (especially  in  the  fasting  condition)  occa- 
sionally a  small  piece  of  gastric  mucosa  may  be  found 
in  the  wash-water.  Such  a  small  piece  of  gastric  mu- 
cosa may  also  be  found  occasionally  in  the  gastric  con- 

'  Minkowski :  "  Mittheilungen  aus  der  med.  Klinik  zu  Konigs- 
berg, "  1888. 

^  Goodsir,  cited  from  Ewald  :  "  Diseases  of  the  Stomach, "  New 
York,  1892,  p.  138. 


78  DISEASES   OF   THE   STOMACH. 

tents  when  examining  the  patient  after  a  test  break- 
fast or  test  dinner.  Boas'  was  the  first  to  make  use  of 
such  specimens  for  microscopical  examination.  He 
was  of  the  opinion  that  such  an  examination  permits 
one  to  judge  of  the  morbid  anatomical  condition  of  the 
given  case.  A  short  time  afterward  I  observed  that 
in  some  cases  the  occurrence  of  small  pieces  of  gastric 
mucosa  in  the  wash-water  is  a  constant  phenomenon. 


$\'iW^W!i 


Fig.  21.— Group  N  (Normal).    A  small  piece  of  gastric  mucosa  (patient  Mrs.  H.) 
presenting  a  cross-section  of  the  glands  in  normal  appearance.     X  80. 

The  number  of  these  pieces  varies  from  one  to  four 
(see  Erosions  of  the  Stomach).  During  the  last  five 
years  I  had  the  opportunity  to  examine  a  great  num- 
ber of  such  small  particles  of  gastric  mucosa,  a 
large  part  of  which  belonged  to  cases  of  erosions  of 
the  stomach,  the  remainder  to  many  other  affections. 
Such  a  piece  of  gastric  mucosa  looks  quite  red.  The 
thickness  may  vary  from  4^  to  1  mm.,  while  the  size  may 
vary  from  that  of  a  large  pin's  head  to  that  of  a  small 

'  J.  Boas  :  L.  c. ,  p.  225. 


EXAMIXATIOX    OF    THE    IXGESTA. 


79 


bean.  Sometimes  they  are  found  embedded  in  mucus. 
While  the  presence  of  glands  in  these  small  pieces  may 
be  found  by  examining  them  in  the  fresh  condition 
under  the  microscope,  a  thorough  examination  can  bo 
made  only  after  a  sufficient  preparation  of  these  par- 
ticles (hardening  in  alcohol,  embedding  in  celloidin 
and  staining  with  eosin,  hsematoxyliu,  picro-carmine, 
methylene  blue,  and  thionin). 


^'' 


C5^ 

Fig.  22.— Group  C  (Connective-Tissue 
Formation).  A  piece  of  gastric  mucosa 
(from  patient  Mrs.  K.  A.)  showing  be- 
ginning atrophy  of  glands  (small  pale 
areas  within  the  glands)  and  connec- 
tive-tissue proliferation.     X  120. 


Fig.  23.— Gi'oup  C  (Connective-Tissue 
Fonnatiou).  Apiece  of  gastric  mu- 
cosa (from  H.  R.  D.)  showing  the 
mouths  of  glands;  the  pale  spots  show 
beginning  atrophy  of  the  glands;  con- 
nective-tissue proliferation  best 
shown  in  lower  part  of  specimen. 
X  120. 


In  examining  the  microscopical  picture  of  tbe  dif- 
ferent specimens  the  following  groups  can  be  easily 
distinguished : 

1.  N  =  Xormal:     glands    and    interglandular    tissue 

exist  in  normal  proportions. 

2.  C= Connective  tissue:  while  there  is  a  normal  pro- 


80  DISEASES    OF    THE    STOMACH. 

portion  between  glands  and  iuterglandular  tissue, 
there  is  a  marked  proliferation  of  connective  tissue 
around  the  glands. 

3.  P  =  Proliferation:  there  is  a  marked  proliferation 

of  glands;  they  are  nearer  each  other  and  some- 
times have  an  elongated  and  curved  shape. 

4.  B  =  Beginning  Atrophy :  the  glands  exist  in  smaller 


:•/'••'/    .-i^-'-ivW     till  V    :::rii"*.' ■':)*:  :'-i:M 

"■tj/B-^P  vvi»^  '^jmi  hm^i 


Fig.  24.  —Group  P  (Proliferation  of  Glands).     A  piece  of  gastric  mucosa  (from 
patient  C.  C),  showing  proliferation  of  glands.    X  80. 

numbers,  and  are  sometimes  also  smaller  in  size; 
the  iuterglandular  spaces  being  quite  large  and 
filled  partly  with  small-cell  infiltration  partly  with 
connective-tissue  formation. 
5.  A  =  Atrophy:  comjilete  atrophy ;  no  glands  visible 
only  indications  of  their  previous  existence ;  round- 
cell  infiltration. 


EXAMINATION   OF    THE    INGESTA. 


81 


A^= Vacuolization :  within  the  glands  exist  vacuoles 
of  different  shape,  being  the  result  of  a  mucoid 
degeneration  of  some  glandular  cells. 


Fi».  25  — Group  B  (Beginning  Atrophy).  A  piece  of  gastric  mucosa  (from  patient 
B.  E.  ■s\'ith carcinoma  cardise),  showing  destruction  of  glands  by  connective-tissue 
proliferation.     X  60. 

Sometimes  one  specimen  shows  characteristics  be- 
longing to  two  of  the  groups  mentioned. 

For  the  beautiful  execution  of  the  drawings  I   am 


^t;l^%' 


.^ 


Fig.  36.— Group  A  (Atrophy).  A  piece  of  gastric  mucosa  (from  patient  R.  H.  D.). 
No  glands  visible,  only  some  empty  spaces  where  glands  had  previously  existed 
X80. 

indebted  to  Dr.  C.  A.  Elsberg,  who  made  them  from 
my  specimens  (see  Figs.  21  to  27).  Although  I 
think   that    the   microscopical   examination   of   these 


DISEASES   OF   THE   STOMACH. 


pieces  of  gastric  mucosa  is  of  great  interest  and 
may  occasionally  help  to  supplement  the  diagnosis, 
I  do  not  believe  that  it  permits  us  to  judge  posi- 
tively about  the  original   affection   of   the   stomach, 


Fig.  27.— Group  V  ^Vacuolization).  A  small  piece  of  gastric  mucosa  (from  patient 
J.  with  carcinoma  pylori),  showing  mucoid  degeneration  of  the  glands  with  vacuo- 
lization; some  connective-tissue  proliferation.     X  140. 

for  in  some  cases  I  have  noticed  in  the  microscopical 
picture  very  few  small  glands,  the  whole  field  hav- 
ing the  appearance  of  atrophy,  and  still  the  gastric 
secretion  was  perfectly  normal.  On  the  other  hand, 
I '  had  a  patient  with  distinct  symptoms  of  chronic 

'  For  further  details  see  Max  Einhorn  :  "  The  State  of  the  Gas- 
tric Mucosa  in  Secretory  Disorders  of  tlie  Stomach,"  Medical  Rec- 
ord, June  27th,  1896. 


EXAMINATION    OF    THE    IXGESTA. 


83 


gastric  catarrh  and  diminished  gastric  secretion  in 
which  the  pieces  of  gastric  mucosa  found  in  the  wash- 
water  presented  a  perfectly  normal  appearance  (Fig. 
21). 

(d)  Particles  of  tumors.  In  the  gastric  contents  ob- 
tained after  test  meals,  in  the  vomited  matter,  in  the 
wash-water  after  lavage  of  the  stomach,  or  within  the 
tube  after  an  exploratory  examination,  small  particles 


Fig.  28.— a  Piece  of  Tumor  (from  B.  E.)  Obtained  after  Examination  with  Stomach 
Tube.  In  fresh  condition  i:  appeared  white  and  was  thicker  and  firmer  than  pieces 
of  gastric  mucosa.  Cross-section  presents  all  appearances  of  alveolar  carcinoma. 
X  140. 

of  tissue  may  be  found.  These,  if  examined  under  the 
microscope,  may  occasionally  reveal  the  nature  of  a 
tumor,  whether  cancerous  or  not.  The  examination 
is  of  importance  if  a  characteristic  picture  of  a  malig- 
nant type  is  discovered.  Most  frequently  such  pieces 
may  be  obtained  in  cases  of  cancer  of  the  cardia.  I 
append  a  drawing  obtained  from  a  specimen  of  such  a 
small  piece  of  cancerous  tissue  from  a  patient  with 
cancer  of  the  cardia  (Fig.  28). 


84  diseases  of  the  stomach. 

Other  Functions  of  the  Stomach. 
1.   Tlie  Absorptive  Function  of  the  Stomach. 

The  absoriDtive  fniiction  of  the  stomach  is  as  a  rule 
tested  by  Penzolclt  and  Faber's'  method.  One  to  two 
decigrams  of  potassium  iodide  are  administered  in  a 
gelatin  capsule  and  the  saliva  is  examined  every  minute 
or  two  for  the  presence  of  iodine.  This  is  done  in  the 
following  manner: 

Strips  of  starch  paper  (filter  paper  saturated  with  a 
starch  solution  and  dried)  are  moistened  with  the 
saliva  of  the  patient  and  then  a  drop  of  fuming  nitric 
acid  is  added.  The  presence  of  iodine  gives  to  the  starch 
paper  a  slightly  violet  or  blue  color.  Under  normal 
conditions,  it  takes  as  a  rule  eight  to  fifteen  minutes 
until  the  appearance  of  this  reaction  in  the  saliva. 

Herschell  "^  described  another  method  of  estimating 
the  absorjitive  power  by  means  of  a  capsule  contain- 
ing 3  decigm.  of  powdered  rhubarb.  If  the  stomach 
be  normal,  this  should  appear  in  the  urine  in  fifteen 
minutes  and  will  give  a  red  color  with  liquor  potassse. 

According  to  my  experience,  the  absorptive  faculty 
of  the  stomach  should  always  be  examined  under  simi- 
lar conditions,  as  the  results  will  differ  materially 
whether  the  test  is  made  in  the  fasting  condition  or 
when  the  stomach  is  full.  It  seems  to  me  that  in 
many  instances  several  writers  have  not  laid  much 
stress  upon  this  point,  and  in  this  way  have  come  to 
wrong  conclusions. 

'  Penzoldt  und  Faber :  "Ueber  die  Resorptionsfahigkeit  der 
ilienschlichen  Magenschleinhaut  und  ihre  diagnostische  Verwer- 
thung."     Bed.  klin.  Wochenschr.,  1882. 

^Herschell;  "Indigestion,"  London,  1895,  p.  115. 


OTHER   FUNCTIONS    OF    THE    STOMACH.  85 

2.  Motor  Function  of  the  Stomach. 

IJDder  motor  function,  as  a  rule,  is  understood  the 
peristalsis  of  the  stomach  and  the  motion  of  the  in- 
gesta  caused  thereby  within  the  organ,  as  well  as  the 
transportation  of  the  food  from  the  stomach  into  the 
intestines.  I  prefer,  however,  to  distinguish  that  func- 
tion which  serves  the  purpose  of  expelling  the  gastric 
contents  (prochoresis) '  from  the  merely  mechanical  mo- 
tions to  which  the  ingesta  are  subjected  within  the  organ 
(anakinesis).'^  This  latter  function  we  shall  describe 
later  on  under  the  heading  of  mechanical  function. 

1.  Leube's  Method.  The  oldest  method  of  ascer- 
taining the  condition  of  the  motor  function  of  the 
stomach  is  that  first  devised  by  Leube.^  It  consists  in 
washing  out  the  stomach  six  to  seven  hours  after  a 
large  meal  (dinner).  Normally  the  stomach  is  found 
empty  at  that  time — that  is  to  say,  all  the  food  has  al- 
ready left  the  organ.  Where  large  quantities  of  food 
are  still  found,  it  shows  that  the  motor  function  is  re- 
tarded. Washing  out  the  stomach  two  to  three  hours 
after  a  smaller  meal,  like  Ewald's  test  breakfast,  may 
serve  the  same  purpose,  for  normally  the  stomach  is 
then  found  empty. 

2.  Eivald  and  Sievers''  Method.  Ewald  and  Sie- 
vers^  have  devised  another,  so  to  speak,  clinical  test, 
for  the  motor  faculty  of  the  stomach.  The  principle 
of  the  test  consists  in  the  property  of  salol,  which  is  a 

'  7]  Ttpoxupwig,  the  advancing. 

2  7j  avaKLvrjaLg,  the  shaking. 

^Leube:  "Krankheiten  des  Magens  und  Darins. "  Ziemssen'p 
'*Handbuch  der  spec.  Path,  und  Therap.,"  Bd.  17,  2te  Halfte. 

■*  Ewald  und  Sievers  :  "Zur  Pathologie  und  Therapie  der  Magen- 
ectasien."     Therap.  Monatshefte,  August,  1887. 


86  DISEASES   OP   THE   STOMACH. 

compound  of  phenol  and  salicylic  acid,  of  not  being 
decomposed  in  acid  solutions.  In  relatively  feeble 
alkaline  fluids  salol  is  decomposed  into  salicylic  acid 
and  phenol  and  then  absorbed.  The  gastric  contents 
always  being  acid,  the  salol  will  not  undergo  any 
changes  there.  After  leaving  the  stomach,  however, 
and  coming  in  contact  with  the  intestinal  juices 
which  are  alkaline,  it  is  quickly  split  up  into  its  two 
components.  The  salicylic  acid  is  then  absorbed  by 
the  blood  and  eliminated  through  the  urine  as  salicyl- 
uric acid.  The  latter  is  easily  recognized  in  the  urine 
by  the  violet  color  produced  on  the  addition  of  neutral 
ferric-chloride  solution. 

The  salol  test  is  made  as  follows:  The  patient  takes 
1  gm.  salol  in  two  gelatinous  capsules  half  an  hour 
after  a  slight  meal.  Before  the  ingestion  of  the  caj)- 
sules  he  empties  his  bladder,  and  then  urinates  every 
half-hour  for  about  two  hours.  All  the  different  speci- 
mens of  urine  are  then  examined  with  ferric  chlor- 
ide solution,  and  it  must  be  ascertained  in  which  speci- 
men the  violet  color  begins  to  appear.  Normally  it 
requires  about  an  hour  until  the  appearance  of  salicyl- 
uric acid  in  the  urine ;  while  in  case  of  retarded  mo- 
tion of  the  stomach  it  takes  two  hours  and  even  longer. 
In  order  to  detect  the  earliest  trace  of  salicyluric  acid, 
Ewald  first  advised  treating  the  urine  with  ether  and 
then  making  the  test  in  the  ethereal  residue.  After- 
ward Ewald  and  I '  suggested  a,  simpler  method  which 
permitted  us  to  dispense  with  the  ether.     This  consists 

'Ewald  unci  Eiuhorn  :  '' Verhandlung.  des  Veieins  f.  innere 
Medicin, "  1888,  p.  58.  Max  Einhorn  :  "  Die  neueren  Methoden  der 
Magenuntersuchung. "    New  Yorker  mediz.  Monatschr. ,  Marz,  1889. 


OTHER   FUNCTIONS    OF    THE    STOMACH.  87 

in  moistsning  a  piece  of  filter  paper  with  the  urine,  and 
then  placing  a  drop  of  ferric  chloride  solution  by  means 
of  a  glass  rod  upon  the  middle  of  the  moistened  paper. 
The  edges  of  the  drop  will  assume  a  violet  color  in  the 
presence  of  even  the  smallest  trace  of  salicyluric  acid. 
These  papers  may  be  dried  and  preserved  and  in  this 
way  one  can  easily  compare  the  reactions  of  the  urine 
in  the  same  patient  at  various  times. 

Huberts  Modification.  Although  normally,  as  a 
rule,  the  salicyluric  acid  appears  in  the  urine  about 
one  hour  after  the  ingestion  of  the  salol,  there  are  ex- 
ceptions in  which  even  in  healthy  people  the  reaction  is 
greatly  retarded.  For  this  reason  Huber  *  suggested 
to  determine  the  length  of  time  required  for  the  com- 
plete disappearance  of  the  reaction  in  the  urine ;  for  it 
is  readily  understood  that  the  longer  the  time  required 
for  the  salol  to  be  absorbed  and  entirely  eliminated 
through  the  urine  the  longer  it  has  remained  within 
the  stomach.  When  the  urine  gives  no  reaction  what- 
ever, it  shows  that  the  whole  amount  of  salol  has  long 
since  left  the  stomach,  and  has  been  eliminated  from 
the  organism.  In  case  of  retarded  motion  of  the 
stomach,  parts  of  the  salol  remain  and  leave  this  organ 
only  after  a  very  long  time.  In  this  way  the  reaction 
of  the  salicyluric  acid  will  extend  over  a  prolonged 
period.  Huber  found  that  normally  the  excretion  of 
the  salicyluric  acid  after  1  gm.  of  salol  lasted  twenty- 
four  hours  ;  in  patients  with  enfeeblement  of  the 
motor  function  of  the  stomach  it  lasted  forty-eight 
hours  or  even  longer. 

'  Huber  :  "  Die  Metlioden  zur  Bestimmung  cler  motorischen  Thatig- 
keit  des  Mageris. "     Corresporiflenzbl.  f.  Schweiz.  Aerzte,  1890. 


88  DISEASES   OF   THE   STOMACH. 

The  salol  test,  as  suggested  by  Ewald  or  as  modified 
by  Huber,  certainly  gives  a  clew  as  to  the  condition  of 
the  motor  function  of  the  organ  and  is  clinically  of 
value,  although  either  of  them  is  by  no  means  ab- 
solutely reliable. 

3.  Klemperer' s  Oil  Test.  Oil  is  not  absorbed  by  the 
stomach  wall.  If,  therefore,  a  certain  quantity  of  oil 
be  ingested  and  the  stomach  emptied  after  a  certain 
period,  it  will  be  possible  to  judge  from  the  amount  of 
oil  withdrawn  the  state  of  the  motor  faculty  ;  for  the 
greater  the  quantity  of  oil  recovered  the  less  has  left 
the  organ.  Klemperer '  proceeds  as  follows:  After 
washing  out  the  stomach,  he  pours  about  100  c.c.  of 
pure  olive  oil  into  the  empty  organ.  Two  hours  later 
the  stomach  is  aspirated  and  whatever  oil  is  left  re- 
moved as  thoroughly  as  possible.  The  difference  be- 
tween the  original  quantity  of  oil  and  that  with- 
drawn indicates  the  state  of  the  motor  function  of  the 
stomach.  According  to  Klemperer,  normally  at  this 
time  only  20  to  40  c.c.  of  the  oil  ought  to  be  found. 
This  method,  however,  is  complicated- and  to  some  ob- 
jectionable; and  as  the  results  obtained  by  it  do  not 
allow  more  conclusions  than  the  method  of  Leube,  it 
has  not  come  into  extensive  practical  use. 

4-.  Examination  of  the  Stomach  in  the  Fasting  Con- 
dition. The  best  and  easiest  way  to  test  the  motor, 
function  of  the  stomach  is  to  examine  this  organ,'by 
means  of  the  tube  and  lavage,  in  the  morning  in  the 
fasting  condition  after  the  ingestion  of  a  substantial 
supper  on  the  night  previous.     Normally  the  stomach 

*  Klemperer :  "Ueber  die  niotorisclieTliatigkeit  desmenschiichen 
Magens. "     Deutsche  nied.  Wochenschr. ,  1888,  No.  47. 


OTHER   FUNCTIONS    OF    THE    STOMACH.  89 

is  empty,  and  therefore  when  the  organ  is  found  to 
contain  a  quantity  of  food,  this  is  the  hest  sign  of 
retarded  motion.  This  method  is  practically  used  by 
most  writers. 

Mechanical  Function. 

Under  the  mechanical  function  of  the  stomach  we 
understand  those  changes  which  arise  in  the  physical 
condition  of  foods  and  are  produced  by  motions  of 
this  organ.  These  motions  are  of  two  characters :  (1) 
active  (peristaltic)  and  (2)  passive  (transmitted,  respi- 
ratory, and  pulsatory).  Both  motions  shake  the  con- 
tents of  the  stomach  and  cause  all  parts  of  the  food  to 
come  into   direct  contact   with  the   gastric   mucosa. 

The  Gastrograph. — Until  recently  there  was  no  way 
of  ascertaining  this  mechanical  function  of  the  stom- 
ach in  the  living.  All  the  experiments  made  with  re- 
gard to  this  subject  have  been  performed  on  laparoto- 
mized  animals.  These,  however,  scarcel}'"  permitted 
any  conclusions  as  to  the  manner  in  which  peristalsis 
of  the  stomach  normally  takes  place;  for  animals 
prepared  for  such  experiments  (after  being  chloro- 
formed or  etherized)  are  certainly  not  normal. 

As  the  mechanical  action  consists  in  the  churning  of 
the  contents,  and  as  by  estimating  the  latter  we  may 
determine  the  first,  I  have  constructed  an  apparatus 
which  indicates  every  motion  to  which  it  may  be  sub- 
jected. The  whole  apparatus  comprises:  1.  The  ball 
(being  the  principal  part).  2.  A  few  electric  cells. 
3.   The  ticker. 

The  ball  (Fig.  29)  consists  of  two  hollow  metallic 


90 


DISEASES   OF   THE    STOMACH. 


hemispheres  (a),  which  are  screwed  together ;  within 
it  is  lodged  and  attached  to  the  upper  hemisphere,  hut 
perfectly  insulated  from  the  same  at  the  attachment, 
another  ball  provided  with  spikes  (b)  radiating  in  all 
directions,  but  not  touching  the  inside  walls  of  the 
hemispheres  ;  another  very  small  platinum  ball  (c)  lies 
within  the  large  ball  and  can  freely  move  in  all  direc- 
tions, knocking  at  the  spikes  (see  Fig.  30).  Two  in- 
sulated wires — one  connected  with  the  hollow  ball,  the 
other  with  the  spiked  ball — ^are  encased  in  a  very  fine, 


HfflfflaUBrasa 


Fig.  29. — The  Ball  Apparatus  of  the  Gastograph  (Einhorn).    Natural  size. 


thin  rubber  tube,  forming  the  cable,  and  separate  at 
the  end  into  two  branches,  which  must  be  attached  to 
an  electric  battery.  As  soon  as  the  platinum  ball 
touches  one  of  the  spikes  an  electric  circuit  is  made  ; 
when,  however,  the  platinum  ball  moves  a  little  way 
and  ceases  to  touch  the  spike  the  current  is  broken. 
At  each  motion  of  the  ball  apparatus  a  rolling  of  the 
little  platinum  ball  takes  place  and  the  electric  current 
is  either  closed  or  broken.  When  the  apparatus  is  at 
rest  there  is  no  change  in  the  current.  On  connect- 
ing the  "ticker"  with  the  battery  and  the  ball, 
each   motion  of  the  latter   will   be   recorded   on  the 


OTHEK   FUXCTIOXS    OF    THE    STOMACH. 


91 


paper  in  showing  the  '"breaks"   and  "makes"  of  the 
current. 

If  the  ball  is  swallowed  and  brought  into  the  stom- 


FiG.  30. — Cross  Section  of  the  Ball,  showing  its  Interior  Construction.  Enlarged 
three  and  a  half  times,  a.  The  two  hemispheres  :  6,  the  spiked  ball ;  c,  theplati- 
Tivan.  ball. 


ach,  the  motions  of  the  former — which  are  caused  by 
the  active  and  passive  motions  of  the  stomach — can 
be  recorded  in  the  way  described. 

I  have  called  this  apparatus  "gastrokinesograph." 
or,  shorter,  ''gastrograph.'- ' 

*  The  gastrograpb  may  be  obtained  of  Eichard  Kny  &  Co. ,  17  Park 
Place,  Xew  York. 


92 


DISEASES    OF    THE    STOMACH. 


From  numerous  tests  which  I  have  made,  it  appears 
with  certaiDty  that  the  gastrograph  works  in  the  de- 
sired manner — i.e.,  it  indicates  the  motions  of  the  hall 
and  can  thus  he   utilized   for   the   valuation  of   the 


Fig.  31.— a  Patient  Undergoing  Examination  with  the  Gastrograph. 

motions  of  the  stomach  or  the  mechanical  action  of 
this  organ. 

Method. — The  hall  is  dipped  in  lukewarm  water,  in- 
troduced into  the  pharynx  of  the  patient,  and  the  latter 


OTHER  FUNCTIONS   OF   THE   STOMACH.  93 

told  to  swallow.  The  patient  may  driDk  some  water. 
After  a  short  while  (from  a  minute  to  a  minute  and  a 
half)  the  ball  reaches  the  stomach.  It  is  advisable  to 
let  the  ball  slip  far  down  into  the  stomach,  so  that  the 
distance  from  the  mouth  to  the  ball  (length  of  cable) 
is  about  50  cm.  The  cable  is  then  connected  with  the 
battery  and  the  indicator  and  the  latter  set  agoing  for 
three  minutes  (Fig.  31).  The  patient  during  this  pro- 
cedure sits  quietly  on  a  comfortable  chair.  At  the  end 
of  three  minutes  the  indicator  is  checked,  the  cable  dis- 
connected from  the  battery,  and  the  ball  withdrawn 
from  the  stomach.  When  at  the  introitus  oesophagi, 
it  is  necessary,  here  in  the  same  way  as  when  using 
the  bucket*  or  the  deglutable  electrode,  to  have  the 
patient  swallow,  and  to  utilize  the  moment  when  the 
larynx  goes  upward  and  forward,  to  withdraw  the 
ball  without  using  any  force  whatever. 

The  strip  of  paper  which  has  rolled  oii  from  the  reel 
is  cut  off  and  the  marks  are  then  perused.  The  black 
line  shows  when  the  current  was  closed,  the  empty 
places  when  there  was  no  current.  As  an  instance  I 
give  a  few  gastrograms  (reduced  ten  times)  (Fig.  32). 
It  is  practical  to  enter  the  marks  of  the  strips  into  a 
copy-book.  This  is  done  in  the  following  way :  Each 
line  is  divided  into  three  equal  spaces — each  space  cor- 
responding to  one  minute — each  space  (or  minute)  into 
ten  divisions,  and  the  "breaks"  and  "makes"  of  the 
current  marked  with  dots  at  the  corresponding  place. 
In  this  way  the  number  of  current  changes  can  very 
easily  be  looked  over  and  comparisons  made. 

»  Max  Einhorn,  Medical  Record,  July  19th,  1890. 


94 


DISEASES   OF   THE   STOMACH. 


(a)  Physiological. — I  have  made  several  tests  veith 
the  gastrograph  on  healthy  people. 

The  experiments  show  that  the  stomach  is  not  so 
inactive  mechanically  as  several  authors  believed,  and 
that  it  churns  the  contents  almost  contin- 
ously  with  slight  periodical  interruptions. 
The  number  of  motions  for  three  min- 
utes averaged  from  four  to  forty-one. 

When  fasting,  the  mechanical  action 
of  the  stomach  seems  to  be  much  less 
than  after  meals. 

(b)  Pathological. — Most  patients  have 
been  examined  with  the  gastrograph 
either  when  fasting  or  from  an  hour  to 
an  hour  and  a  half  after  the  test  break- 
fast, taking  about  half  a  glassful  of 
water  when  swallowing  the  ball;  many 
of  the  patients  have  been  examined  under 
both  conditions  on  different  days.  Some 
of  them  have  been  subjected  to  a  very 
great  number  of  tests,  in  order  to  ascer- 
tain whether  there  is  a  certain  coiDstancy 
in  the  results.  The  whole  number  of 
patients  examined  was  twenty-seven,  the 
number  of  tests  sixt3'-four. 

In  perusing  the  gastrograms  obtained 

from  my  patients  and  comparing  them 

with  those  obtained  from  healthy  people, 

there  are  three  different  classes  among 

them.     One  corresponds  to  the  normal  ;  the  second 

class  is  marked  with  too  much  mechanical  action,  the 

number   of   dots  being  greatly  increased  ;  the  third 


OTHER   FUNCTIONS    OF   THE    STOMACH,  95 

class  shows  a  remarkable  slowness  and  sluggishness  of 
the  mechanical  function,  the  number  of  dots  being 
reduced  to  4,  3,  or  0. 

Hemmeter-Morntz' s  Method. — As  the  gastrograph 
does  not  permit  of  a  distinction  between  the  active  and 
passive  motions  of  the  stomach,  Dr.  J.  C.  Hemmeter,' 
of  Baltimore,  has  recently  devised  another  method  for 
testing  the  gastric  peristalsis.  The  essential  part  of  the 
apparatus  is  a  deglutible  elastic  stomach-shaped  bag  of 
very  thin  rubber  and  attached  to  an  oesophageal  tube. 
The  stomach-shaped  pouch  has  the  shape  of  the  stom- 
ach only  when  it  is  blown  up.  It  does  not  occupy 
much  space  when  it  is  collapsed  and  can  be  introduced 
without  difficulty  into  the  stomach  of  patients.  The 
oesophageal  tube  maybe  very  small,  not  quite  half  the 
size  of  the  ordinary  tube  used  in  lavage.  When  the 
bag  has  reached  the  stomach,  which  can  be  determined 
by  a  mark  previously  made  on  the  tube,  it  is  filled 
with  air  and  connected  either  Vv'ith  a  water  manometer 
or  tambour  on  the  Ludwig  kymograph.  The  slightest 
contraction  of  the  involuntary  fibres  of  the  gastric  mus- 
cle layer  will  compress  the  very  elastic  intragastric  bag 
and  distend  the  tambour,  to  which  a  glass  bulb  ink  jDen 
is  attached,  recording  the  gastric  peristalsis  as  the 
clockwork  moves  the  paper  along.  On  the  upper  mar- 
gin of  the  kymographion  paper  a  record  pen  connected 
with  a  chronometer  indicates  seconds  on  the  record  by 
small  dots,  so  that  it  is  possible  to  determine  the  time 
of  occurrence  and  duration  of  the  gastric  peristalsis. 
As  the  stomach  perceptibly  moves  with  every  inspira- 
tion and  expiration,  a  pneumograph  is  tied  around  the 

'  J.  C.  Hemmetei- :  New  York  Medical  Journal,  June  22d,  1895. 


96  DISEASES   OF   THE   STOMACH. 

patient's  waist  recording  every  respiratory  movement 
on  the  kymograph.  It  will  be  seen  on  the  tracing  that 
many  movements  of  the  pen  connected  with  the  intra- 
gastric bag  are  passive  and  cansed  by  the  act  of  respi- 
ration, but  there  are  other  very  high  and  long  excur- 
sions of  the  gastric  pen  which  are  independent  of 
the  movement  of  the  pneumographic  pen,  or  occur 
when  respiration  is  suspended  for  a  short  while. 
These  are  the  muscular  contractions  proper  of  the 
stomach.  The  same  method  has  been  independently 
used  and  described  by  Moritz,  of  Munich. 

In  his  paper  Hemmeter  says :  "In  making  studies  on 
the  kymograph  on  the  gastric  motility,  only  such  pa- 
tients are  taken  as  have  become  accustomed  to  the 
stomach  tube,  as  the  nausea  and  vomiting  first  attend- 
ing the  initial  introduction  of  the  tube  make  an  exact 
record  impossible." 

This  sentence  shows  that  this  apparatus  cannot  be 
applied  without  difficulty  and  for  this  reason  appears 
unsuitable  for  practical  purposes.  Although  the  gas- 
trograjDh  does  not  permit  a  distinction  between  the  ac- 
tive and  passive  movements,  it  affords,  nevertheless, 
an  accurate  idea  as  to  the  mechanical  action  as  such, 
for  the  passive  movements  certainly  also  participate  in 
this  function  of  the  stomach  and  should  not  be  ignored. 
In  this  way  I  think  that  the  gastrograph  method,  not 
being  so  complicated  and  being  easily  performed,  pre- 
sents many  advantages  over  Hemmeter's  apparatus. 


CHAPTER   III. 

DIET. 

Dietetics  comprise  the  study  of  nutrition  in  health 
and  disease  and  of  the  substances  serving  for  this  pur- 
pose (the  diet).  All  living  organisms  derive  their 
nourishment  from  the  vegetable  kingdom,  either  di- 
rectly, or  indirectly  by  living  upon  animals  which  in 
turn  live  upon  a  vegetable  diet.  Foods  are  substances 
vs^hich  are  required  for  the  nutrition  and  maintenance 
of  the  body ;  they  replace  its  wastes  and  losses. 

In  studying  the  normal  nutrition  of  man  we  perceive 
quickly  that  there  is  a  great  variety  in  the  food  of 
healthy  persons  with  regard  to  the  quantity  as  well  as 
to  the  different  food  substances.  Nevertheless,  they 
all  contain  the  three  groups  of  food-stuffs :  Albumin, 
carbohydrates,  and  fats.  Thus,  for  instance,  vegeta- 
rians live  and  thrive  principally  on  vegetables ;  the  Es- 
quimaux, on  the  other  hand,  almost  exclusively  on  ani- 
mal diet.  The  golden  path,  however,  lies  intermediate, 
and  all  authors  (Voit,  Pettenkofer,  Hoffmann,  Forster, 
and  Gruber)  recommend  a  combination  of  animal  and 
vegetable  food.  E.  Virchow  likewise  is  of  the  same 
opinion,  and  expresses  himself  regarding  this  question 
as  follows :  "  Although  the  Kirghez  and  the  Esquimaux 
show  us  that  health  and  life  can  exist  through  many 
generations  on  an  exclusively  nitrogenous  diet — other 
tribes  (Hindoos)  live  principally  on  non-nitrogenous 
food — still  history  shows  us  that  the  highest  attain- 


98  DISEASES   OF   THE   STOMACH. 

meiits  of  the  human  race  have  emanated  from  nations 
who  have  lived  and  live  on  mixed  diet."  A  mixed 
diet,  taken  partly  from  the  vegetable  and  partly  from 
the  animal  kingdom,  is  the  most  suitable  form  of  nour- 
ishment. We  obtain  the  greatest  amount  of  carbo- 
hydrates from  the  vegetable  kingdom,  while  a  great 
deal  of  the  albumin  is  derived  from  animal  food.  The 
relation  between  animal  and  plant  albumin,  according 
to  Munk  and  Uffelmann,'  should  not  be  less  than  three 
to  seven.  As  regards  the  quantity  of  food,  according 
to  the  same  authors,  an  adult  doing  a  medium  amount 
of  work  requires  daily  118  gm.  albumin,  56  gm.  fat, 
and  500  gm.  carbohydrates. 

Food  only  in  small  portions  serves  the  purpose  of  re- 
constructing tissue  waste ;  in  its  largest  part,  however, 
it  is  used  for  generating  the  heat  requisite  for  the 
maintenance  of  life.  For  that  reason  it  is  customary 
to  speak  of  the  necessary  amount  of  heat  units  during 
twenty-four  hours  instead  of  the  quantity  of  food. 
By  "heat  unit"  is  meant,  as  is  well  known,  that  quan- 
tity of  heat  which  is  required  to  raise  the  temperature 
of  1  gm.  of  water  1°  C.  "Great  heat  unit"  means  the 
amount  of  heat  required  for  warming  1,000  gm.  of 
water  1°  C.  Each  kind  of  food  is  ultimately  oxidized 
in  the  body  to  its  end  products,  and  is  in  greatest  part 
exhaled  in  the  form  of  carbonic  acid  ;  the  more  carbon 
atoms  a  food-stuff  contains  the  more  heat  units  it  will 
generate.  In  speaking  of  the  heat  value  of  food,  the 
great  beat  units  are  used,  the  term  "great,"  however, 
being  omitted.     Thus  1  gm.  of  albumin  generates  4.1, 

'Munk  und  UflFolniann :  "Die  Ernahrung  des  gesunden  und 
kranken  Menschen,"  Wien,  1887. 


DIET. 


99 


1  gin.  of  fat  9.3,  and  1  gm.  of  carbohydrate  4.1  heat 
units.  If  we  know  the  quantity  of  nourishment  taken, 
the  amount  of  the  introduced  heat  units  is  easily  deter- 
mined by  multiplying  the  different  food -stuffs  by  the 
above-given  figures.  The  daily  amount  of  heat  gen- 
erated by  the  body,  or  necessary  for  the  maintenance 
of  the  same,  has  been  approximately  estimated  at 
twenty-five  hundred  heat  units.'  The  heat  value  of 
the  food  taken  by  an  average  working  person  amounts, 
according  to  von  Noordeu,"  to  about  forty  heat  units 
when  working,  and  when  resting  to  about  thirty-four 
heat  units  per  kilogram  a  day. 

The  following  table  of  the  composition  of  the  dif- 
ferent foods  and  the  amount  of  heat  units  they  produce 
will  make  it  easy  to  figure  out  whether  a  certain 
known  quantity  of  taken  nourishment  is  sufficient  to 
maintain  the  body  in  balance  or  not. 


COMPOSITION  OF  THE  MOST  COMMON  FOOD  SUBSTANCES. 
I.  Dairy  Products. 


Albumin, 
per  cent. 

Fat, 
per  cent. 

Carbohydrate, 
per  cent. 

Calories, 
per  100. 

Cow's  milk 

4.0  to  4.3 
3.61 
0.5 
0.5 
3.0 

3.35 

25.0 
33.0 
12.5 

3.0  to  3. 8 
26.75 
90.0 

0.3 

1.3 

r 

1 

2.07^ 

I 
30.0 
9.0 
12.0 

3.7 

3.52 

0.5 

3.6 

3.0 
0.7    lactic 

acid 
1.9  alcohol 
0.8  carbonic 
acid 

3.0 

5.0 

0.5 

64 

Cream 

276.01 

Butter 

837 

Whey 

Buttermilk 

3.67 

Kumyss  (of  cow's  milk) 

Cheese  (cream)  

Cheese 

32.99 

394 
240 

Eg-p- 

165 

'Koetiig:    "Die    menschlichen  Nahrungs-    und  Genussmittel, 
Berlin,  1883,  p.  53. 

2  Von  Noorden  :  Berliner  Klinik,  Heft  55. 


100 


DISEASES   OF   THE    STOMACH. 
II.  Meats  and  Game. 


Albumin, 
per  cent. 


Beef  (fat) 

Beef  (lean) 

Veal  (fat) 

Veal  (lean) 

Mutton  (very  fat) 

Mutton  (leaner) 

Pork  (fat) 

Pork  (lean)   

Ham  (Westphalian)  . 

Sweetbread 

Pulverized  meat 

Poultry 

Spring  chicken 

Duck  (wild) 

Squab 

Game 

Hare 

Venison 


17.19 

20. 78 

18.88 

19.84 

14.80 

17.11 

14.54 

20.25 

23.97 

22.0 

64.5 

22.0 

18.49 

22.65 

22.14 

23.0 

23.34 

19.77 


Fat, 
per  cent. 


26.38 
1.50 
7.41 
0.82 

36.39 
5.77 

37.34 
6.81 

36.48 
0.4 
5.24 
1.0 
9.34 
3.11 
1.00 
1.0 
1.13 
1.92 


Carbohydrate, 
per  cent. 


0.07 
0.05 

'iVsb 

2.28 

1.20 
2.33 
0.76 

O.V9 
1.42 


Calories, 
per  100. 


315.81 
99.15 
146.61 
86.97 
399.31 
123.81 
406.88 
146.36 
453.69 
93.92 
322.53 
100 
167.59 
131.36 
100.07 
103.60 
107.08 
105.44 


III.  Fish. 


Albumin, 
per  cent. 

Fat, 
per  cent. 

Carbohydrate, 
per  cent. 

Calories, 
per  100. 

Pike 

18.5 
20.61 
17.09 
15.01 
22.30 
4.95 
19.5 
28.04 

0.5 
1.09 
9.34 
6.42 
2  21 

o.h 

17.0 
16.26 

0.75 

2.85 
0.45 

o.'s 

7.82 

83.57 

Carp        

94.64 

Shellfish 

156.93 

Salmon 

132.93 

Sardellen       

113.83 

Oysters 

24 

Salt  herring 

Caviar      

IV.  Cereals  and  Vegetables. 


Albumin, 
per  cent. 

Fat, 
per  cent. 

Carbohydrate, 
per  cent. 

Calories, 
iper  100. 

Sago = . . . 

0.5 
8.5 
10.0 
6.0 
4.5 
6.82 
9.5 
2.0  to  5.0 

traces 
1.25 
2.0 
0.75 
1.0 
0.77 
1.0 
0.4 

86.5 
73.0 
69.0 
52.0 
46.0 
43.72 
75.0 
4.0 

356.70 

Wheat  flour 

345.78 

Rve  flour 

342.50 

Wheaten  bread 

245 

Rve  bread 

216 

Roll            

213.87 

Zwieback        

356 

Cauliflower 

35 

DIET. 

IV,  Cereals  and  Vegetables. — Continued. 


101 


Albumin, 
per  cent. 

Fat, 
per  cent. 

Carbohydrate, 

per  cent. 

Calories, 
per  100. 

Carrots 

1.04 

2.0 

5.5 

19.5 

19.5 
1.5 

12.5 
8.31 
3.49 
1.02 

0.31 

0.3 

1.5 

2.0 

2.0 

5.26 

0.81 
0.58 
0.09 

6.74 
2.5 
76.0 
53.0 
54.0 
20.0 
66.77 
75.19 
4.44 
0.95 

33  85 

Asparagus 

21 

Rice 

348.10 

Beans 

311  75 

Peas 

319.95 

Potatoes 

88 

Oatmeal 

338.80 

Barley  meal 

323 

Spinach  

38 

Pickles 

V.  Soups  and  Beverages. 


AlbTimin, 
per  cent. 

Fat, 
per  cent. 

Carbohydrate, 
per  cent. 

Calories, 
per  100. 

Milk    soup    with  wheat 
flour 

5.0 

0.4 

6.0  to  7.0 

0.5 

9.0    to    11.0 

albumin 

+  1.79  to  6.5 

peptone 

8.0  to  10.0 

1.5 

8.8 

3.12 

12.38 

0.5 

0.7 

3.25 
0.6 
0.5 
0.5 

i'.o* 

3.0 

5.18 

5.35 
6.0 

15.0 

55.0 
11.0 
28.6 

0.3 

0.3 

113 

Meat  broth  (ordinary)  . . 

Meat  juice  (pressed) 

Beef  tea 

r 

Leu  he's  meat  solution.  ^ 
Malt  extract 

358  30 

Barley  soup 

60.96 

Rice  pap  with  milk 

Coffee 

183.61 

Tea 

Beer 

Porter 

60 

VI.  Fruits. 


Free  acid, 
per  cent. 

Albumin, 
per  cent. 

Fat, 
per  cent. 

Carbohydrate, 
per  cent. 

Apples 

0.83 
0.20 
1.50 
0.92 
0.79 
0.93 

0.36 
0.36 
0.40 
0.65 
0.59 
0.54 
5.48 

I'.SO 

0.45 
1.37 

7  23 

Pears 

3  54 

Plums  

4  68 

Peaches 

7  17 

Grapes 

Strawberries 

Chestnuts 

1.96 

1.01 

38.34 

Sugar  cane 

3.40 

Honey 

5.28 

102  DISEASES   OF   THE   STOMACH. 

AccordiDg  to  K.  Yierordt '  an  adult  takes  iu  form  of 
food  a  daily  average  of  120  gm.  albumin,  90  gm.  fat, 
330  gm.  carbohydrate  (the  relation  of  the  nitrogenous 
food-stuffs  to  the  non-nitrogenous  being  1  to  4),  and 
2,818  gm.  of  water.  The  above-mentioned  figures  dif- 
fer from  those  given  by  F.  Hirschfeld.'  This  author 
considers  SO  gm.  of  albumin  as  the  lov^^est  amount  con- 
tained in  a  sufficient  diet.  Some  experiments  which 
IMiave  made  in  order  to  determine  the  amount  of 
nourishment  taken  by  myself  during  the  summer 
showed  figures  which  resembled  those  of  Hirschfeld. 
The  quantity  of  albumin  was  79.39,  fat  54.3  and  car- 
bohydrate 263.9;  the  total  of  heat-units  equalled 
1,912,5.  The  amount  of  heat-units  per  kilogramme  a 
day  was  32.2.  Victuals  are  composed  mostly  of  all 
the  three  food  groups  (albumin,  carbohydrate,  fat)  and 
water,  and  contain  in  minute  amounts  the  inorganic 
salts  found  in  the  body. 

We  are  accustomed  to  speak  of  easily  digestible 
foods,  and  those  difficult  of  digestion.  The  term  of 
easily  or  less  digestible  cannot,  however,  be  explained 
without  some  qualifications.  Many  writers  judge  the 
digestibility  of  foods  by  the  length  of  time  they  re- 
quire for  their  digestion  in  the  stomach.  Penzoldt* 
has  lately  made  many  investigations  with  regard  to 
the  sojourn  of  food  in  the  stomach  in  health.  He, 
however,  lays  stress  on  the  distinction  between  gastric 

'  K.  Vierordt :  "  Grundriss  der  Pli5-siologie  des  Menschen, "  1887, 
3  Auflage,  pp.  288,  289. 

2  F.  Hirschfeld:  Berliner  klin.  Wochenschr.,  1893.  No.  14. 

'  Max  Einhom  :  "  Dietetics  in  Diseases  of  the  Stomach. "  Medical 
Record,  June  24th.  1893. 

*  Penzoldt  und  Stinzing :  "Handbuch  der  speciellen  Therapie 
innerer  Krankheiten,"  Jena,  1895. 


DIET.  103 

and  intestinal  digestibility,  the  former  being  recog- 
nized by  the  length  of  time  the  food  remains  in  the 
stomach,  the  latter  being  measured  by  its  more  or 
less  complete  utilization  or  assimilation,  that  is,  the 
amount  of  residue  excreted  with  the  faeces.  In  giving 
a  list  of  the  digestibility  of  different  foods  I  follow 
Penzoldt's  views. 

A.  Animal  Foods. 

These  comprise  besides  the  flesh  (muscles)  of  the 
different  mammals,  birds,  and  fishes  several  other  por- 
tions of  their  bodies,  as,  for  instance,  various  glands, 
brain,  lung,  liver,  etc.  Oysters  and  lobsters  also  be- 
long to  this  group.  In  most  instances  the  digestibility 
of  this  group  of  foods  corresponds  to  their  richness  in 
fat.  The  less  fat  they  contain  the  more  digestible 
they  are.  Thus  we  have  the  following  list  of  animal 
foods  classified  according  to  their  digestibility : 

Fat 
per  cent. 

Calf's  sweetbread,  veal,  cod-fish,  pike,  oysters 0.4  to  1 

Beef,  hare,  spring  chicken,  pigeon,  partridge,  carp 1  to  1|- 

Mutton,  pork 5  to  7 

Goose,  caviar,  herring,  salmon,  eel over  8 

The  digestibility  of  food  is  greatly  dependent  on  its 
quality  and  preparation.  Young  animals  have  soft 
and  tender  meat,  whereas  the  flesh  of  old  ones  is 
tough.  The  different  portions  of  the  body  vary  also 
frequently  in  their  digestibility.  The  time  that  has 
passed  since  the  killing  of  the  animal  is  also  of  impor- 
tance. Fresh  meat  which  is  yet  in  its  rigid  state  is 
tough  and  therefore  very  indigestible.     In  the  prepar- 


104  DISEASES   OP   THE   STOMACH. 

ation  of  the  meat  we  must  see  that  it  is  separated  from 
all  indigestible  matter  (fascia,  tendons,  cartilage). 
By  pounding  the  meat  the  connective  tissue  surround- 
ing the  muscle  fibre  is  torn.  By  chojDping,  scraping, 
or  grinding  the  meat,  its  digestibility  is  increased. 
All  other  methods  of  preparing  meat  serve  to  improve 
its  taste.  For,  according  to  Penzoldt,  raw  meat  is 
more  easily  digested  than  that  which  has  been  boiled, 
broiled,  or  fried.  The  application  of  heat  also  di- 
minishes the  danger  of  infection,  as  many  micro- 
organisms are  destroyed  by  it. 

Eggs  are  especially  rich  in  albumin  and  fat.  Ac- 
cording to  Penzoldt,  soft-boiled  eggs  (three  minutes  in 
boiling  water)  are  easiest  to  digest.  Then  come  raw 
eggs  and  scrambled  eggs,  while  hard-boiled  eggs  and 
omelet  souffle  are  difficult  of  digestion.  (Soft-boiled 
eggs  remain  in  the  stomach  one  and  three-quarter 
hours,  hard-boiled,  three  hours). 

Milk  is  intended  as  the  sole  food  of  young  animals 
and  as  such  contains  all  the  elements  of  a  typical  diet : 
(1)  Albuminous  substances  in  the  form  of  casein  and 
serum  albumin  ;  (2)  fats  in  cream  ;  (3)  carbohydrates 
in  the  form  of  lactose  or  milk  sugar ;  (4)  salts,  chiefly 
calcium  phosphate ;  and  (5)  water.  Milk  does  not  stay 
in  the  stomach  much  longer  than  plain  water  and  must 
therefore  be  considered  very  digestible. 

Several  articles  of  food  are  obtained  from  milk : 

(a)  Cheese,  which  is  the  casein  precipitated  with 
more  or  less  fat,  according  as  the  cheese  is  made  of 
skimmed  milk  (skim  cheese),  or  fresh  milk  with  its 
cream  (Cheddar  and  Cheshire),  or  of  fresh  milk  plus 
cream  (Stilton  and  Double  Gloucester).     The  precipi- 


DIET.  105 

tated  casein  is  allowed  to  ripen,  by  which  process  some 
of  the  albumin  is  split  up  with  formation  of  fat. 

(6)  Cream  consists  of  the  fatty  globules  encased  in 
casein  and  which,  being  of  lowest  specific  gravity, 
rise  to  the  surface. 

(c)  Butter  or  the  fatty  matter  deprived  of  its  casein 
envelope  by  the  process  of  churning. 

{d)  Buttermilk  is  the  fluid  obtained  from  cream 
after  butter  has  been  formed.  It  is  therefore  very 
rich  in  nitrogen. 

(e)  Whey  is  the  fluid  which  remains  after  the  pre- 
cipitation of  casein.  It  contains  sugar,  salt,  and  a 
small  quantity  of  albumin. 

B.    Vegetable  Foods. 

All  of  these  contain  more  or  less  carbohydrates,  and 
the  principal  amount  of  carbohydrates  of  our  diet  is 
obtained  from  them. 

1.  Foods  rich  in  proteids.  Leguminous  foods 
(peas,  beans,  lentils,  etc.)  contain  a  nitrogenous  sub- 
stance called  legumin,  which  is  allied  to  albumin,  in 
the  proportion  of  twenty-five  per  cent.  They  form  a 
chief  source  of  the  nitrogen  of  the  food  of  vegetarians. 

2.  Foods  rich  in   carbohydrates  : 

(a)  Cereals.  Bread  made  from  the  ground  grain 
obtained  from  various  so-called  cereals,  namely,  wheat, 
rye,  maize,  barley,  rice,  oats,  etc.,  is  the  direct  form 
in  which  the  carbohydrate  is  supplied  in  an  ordinary 
diet.  Besides  starch  it  contains  gluten,  a  nitrogenous 
body,  and  a  small  amount  of  fat.  White  bread  is 
easier  to  digest  than  brown  bread.  Various  articles 
are  made  from  fiour:  sago,  macaroni,  biscuits. 


106  DISEASES   OF   THE   STOMACH. 

{b)  Vegetables  (rice,  iDotatoes).  They  contain  chiefly 
starch  and  sugar. 

(c)  Green  vegetables  (cauliflower,  asparagus,  tur- 
nips, cabbage,  carrots,  spinach,  string  beansj  are  es- 
pecially rich  in  salts. 

Almost  all  vegetables  are  not  eaten  in  their  raw 
state,  but  after  being  cooked.  The  cooking  produces 
the  necessary  effect  of  rendering  them  softer  so  that 
they  can  be  more  readily  broken  up  in  the  mouth. 
It  also  causes  the  starch  grains  to  swell  up  and  burst 
and  so  aids  the  digestive  fluids  in  penetrating  into 
their  substance.  The  albuminous  matter  is  coagulated 
and  the  gummy,  saccharine,  and  saline  matters  are  re- 
moved. The  conversion  of  flour  into  dough  is  effected 
by  mixing  it  with  water  and  adding  a  little  salt  and  a 
certain  amount  of  yeast.  It  is  by  the  growth  of  the 
yeast  which  lives  upon  the  sugar  produced  from  the 
starch  of  the  flour  that  a  quantity  of  carbonic-acid 
gas  and  alcohol  is  formed.  By  means  of  the  former 
the  dough  rises.  By  the  action  of  heat  during  baking 
the  dough  continues  to  expand,  and  the  gluten  being 
coagulated,  the  bread  sets  as  a  permanently  vesiculated 
mass. 

(d)  Fruit  (pears,  apples,  etc.).  They  all  contain 
sugar  and  organic  acids  like  tartaric,  malic,  citric,  and 
others. 

C.  Liquid  Foods. 

Water  is  consumed  alone  or  together  with  certain 
other  substances  added  for  flavoring  purposes,  tea, 
coffee,  etc. 

Tea  in  moderation  is  a  stimulant  and  contains  an 


DIET.  107 

aromatic  oil  to  which  it  owes  its  peculiar  aroma,  an 
astringent  of  the  nature  of  tannin,  and  an  alkaloid, 
theine.  The  composition  of  coffee  is  very  similar  to 
that  of  tea.  Cacao,  in  addition  to  similar  substances 
contained  in  tea  and  coffee,  contains  fats,  albuminous 
matter,  and  starch,  and  must  be  looked  upon  more  as 
a  food. 

Beer  in  various  forms  is  an  infusion  of  malt  (barley 
which  has  been  sprouted  and  the  starch  of  which  is 
converted  in  great  part  into  sugar)  boiled  with  hops 
and  allowed  to  ferment.  It  contains  from  one  to  eight 
per  cent  of  alcohol. 

Cider  is  the  fermented  juice  of  apples  ;  wine  the  fer- 
mented juice  of  grapes  and  contains  from  six  or  seven 
(Rhine  wine  and  white  and  red  Bordeaux)  to  twenty- 
four  per  cent  (Ports  and  Sherries)  of  alcohol.  Spirits 
obtained  from  the  distillation  of  fermented  liquors 
contain  upward  of  forty  to  seventy  per  cent  of  ab- 
solute alcohol. 

Utilization  of  Food. 

The  amount  of  utilization  of  the  food  by  the  diges- 
tive tract  has  been  studied  by  Rubner,  and  according 
to  his  investigations  the  residues  of  the  different  food- 
stuffs, that  is,  the  indigestible  matter,  are  least  under 
a  diet  of  animal  food  and  highest  under  one  consisting 
of  vegetables.  He  gave  the  following  scale:  Meat, 
eggs,  macaroni,  white  bread,  milk,  rice,  maize,  carrots, 
cabbage,  potatoes,  brown  bread. 

Diet  in  Health. 

The  diet  in  health  should  not  always  comprise  the 
most  easily  digestible  substances.     For  by  doing  so  we 


108  DISEASES   OF  THE   STOMACH, 

weaken  our  digestive  system.  Although  it  is  not 
necessary  always  to  choose  the  substances  which  are 
hard  to  digest,  it  is  certainly  not  necessary  to  avoid 
them.  The  food  should  consist  of  mixed  substances 
(easy  and  difficult  to  digest)  and  should  always  pre- 
sent a  sufficient  variety.  As  to  the  distribution  of 
meals  and  also  as  to  the  predominance  of  the  different 
food  articles  in  diet  it  is  impossible  to  give  the  same 
rule  for  all.  Good  use  and  custom  is  the  best  and 
most  important  guide. 

Dietetics  in  Diseases  of  the  Stomach. 

Within  the  past  five  years  important  facts  have  been 
discovered  which  are  of  the  greatest  value  in  the  treat- 
ment of  diseases  of  the  stomach,  and  the  influence  of 
which  can  be  perceived  like  a  red  thread  through  the 
whole  chapter  of  dietetics.  It  has  been  shown  by  von 
Noorden '  and  others  that  emaciation  in  chronic  dis- 
eases of  the  stomach  is  caused  in  the  largest  majority 
of  cases — if  not,  perhaps,  in  all — not  by  specific  poi- 
sons circulating  in  the  organism,  but  by  a  smaller 
amount  of  food  being  taken.  On  the  other  hand,  one 
might  expect,  judging  from  the  universal  law  existing 
in  the  plant  and  animal  kingdom  of  vicariousness  or 
replacement  in  case  of  inability  of  the  work  of  one 
organ  by  another  similar  one,  that  in  grave  disturb- 
ances of  the  digestive  functions  of  the  stomach  the  in- 
testines would  do  the  work  instead.  This  has  been 
experimentally,  as  well  as  clinically,  proven  in  the  most 
infallible  way.  Several  authors  (Leube,  Ewald,  von 
Noorden)  have  observed  that,  in  cases  of  atrophy  of  the 

'  Von  Noorden  :  Berliner  Klinik,  Heft  55. 


DIET.  109 

mucous  membrane  of  the  stomach  in  ^vhich  the  gas- 
tric secretion  has  entirely  ceased,  the  patients  can 
maintain  their  usual  weight.  In  my  paper  on 
"Achylia  Gastrica"' '  it  is  clearly  shown  that  the  pa- 
tients can  do  very  well  without  gastric  secretion ;  under 
a  proper  regimen  they  can  even  gain  in  weight,  and  live 
long  without  any  discomfort  whatever.  That  means 
that  even  after  the  loss  of  the  entire  chemical  action  of 
the  stomach,  the  gut  is  completely  able  to  replace  the 
function  of  the  stomach. 

These  two  facts — (1)  that  the  emaciation  in  chronic 
diseases  of  the  stomach  is  caused  by  too  small  a  quan- 
tity of  food ;  (2)  that  even  in  grave  lesions  of  the  gas- 
tric functions  the  gut  appears  to  perform  vicariously 
the  digestive  work  in  a  complete  way — are  of  vital  im- 
portance for  the  doctrine  of  dietetics.  For  it  is  seen 
at  a  glance  that  the  main  object  of  nutrition  of  the  sick 
consists  in  giving  them  sufficient  quantities  of  food. 

As  people  with  disturbances  of  the  stomach  have  to 
replace  for  their  existence  no  smaller  losses  than  under 
physiological  conditions,  they  will  therefore  need:  1. 
Just  as  large  amounts.  2.  The  same  kinds  of  food- 
stuffs as  described  for  the  normal  state.  The  only 
difference  possible  will  have  reference  to  the  selection 
of  the  various  articles  of  food  and  to  their  form  and 
special  preparation. 

Thus  the  question  arises.  What  qualities  should  the 
food  of  the  stomach  patients  possess? 

In  the  treatment  of  a  diseased  organ  one  can  often 
make  use  of  two  methods.  One  consists  in  sparing 
the  diseased  organ  and  giving  it  perfect  rest,  the  other 
1  Max  Einhorn  :  Medical  Record,  1893. 


110  DISEASES   OF  THE   STOMACH, 

consists  in  strengthening  the  same  by  methodical  adap- 
tation for  more  work  and  practice.  Both  principles 
are  in  fact  realized  in  the  treatment  of  diseases  of  the 
stomach.  The  first  method  is  ordinarily  applied  in 
acute  diseases  and  but  very  seldom  (and  then  only  for 
a  short  time)  in  chronic  affections  of  the  stomach.  In 
these  latter  the  second  princijDle,  as  a  rule,  is  used. 
The  stomach  can  be  spared,  firstly,  by  not  introducing 
into  it  any  food  whatever  (greatest  degree  of  saving 
or  rest).  Secondly,  by  administering  food  substances 
which,  during  their  stay  in  the  stomach,  do  not  impose 
much  w^ork  upon  this  organ,  and  do  not  greatly  irritate 
it.  Here  the  main  object  will  be  to  give  the  patient 
easily  digestible  food.  In  turning  from  the  saving 
principle  to  that  of  strengthening  the  organ  by  method- 
ical adaptation  for  w^ork,  it  will  be  quite  natural  to 
change  the  diet,  not  suddenly,  but  gradually,  into 
such  as  requires  more  work  on  the  part  of  the  stomach 
for  its  digestion.  It  is  therefore  absolutely  necessary 
to  have  an  exact  table  of  the  digestibility  of  different 
foods.  In  prescribing  or  changing  a  diet  we  shall 
have  to  act  according  to  it.  Such  a  scale  has  been 
arranged  by  different  authors.  The  main  sign  of  di- 
gestibility was  gauged  as  mentioned  above  by  the 
rapidity  with  w^hich  the  various  food-stuffs  passed  out 
of  the  stomach  into  the  intestines.  Beaumont,  in 
many  trials  on  his  patient  with  the  gastric  fistula,  deter- 
mined the  length  of  time  the  different  victuals  re- 
mained in  the  stomach  and  constructed  a  scale  ac- 
cording to  the  figures  obtained. 

On  the  same  principle,  but   more  reliable   and    of 
greater  value,  is  the  scale  constructed  by  Leube,  ac- 


DIET.  Ill 

cording  to  the  results  obtained  by  emptying  the  stom- 
ach of  patients  by  means  of  a  tube,  after  different 
kinds  of  food  had  been  taken.  We  think  it  advisable 
and  useful  here  to  give  Leube's  scale: 

1st  Diet. — Bouillon,  Leube-Rosenthal's  meat  solu- 
tion, milk,  soft  raw  eggs,  zwieback,  English  cakes 
(biscuits  containing  no  sugar),  water,  natural  acidu- 
lous waters  (Apollinaris,  Kronthaler,  Seltzer,  etc.). 

^d  Diet. — Boiled  calf's  brain,  boiled  calf's  sweet- 
bread, boiled  chicken  (young  without  the  skin),  boiled 
pigeon,  boiled  calves'  feet,  tapioca  pap  boiled  in  milk, 
beaten  white  of  egg. 

3cl  Diet. — Eaw  beef  (chopped  very  fine),  raw  ham 
(chopped  very  fine),  beefsteak  (superficially  fried  in 
freshest  butter),  finely  scraped  tenderloin  of  beef, 
mashed  potatoes,  white  bread  (stale),  coffee  with  milk, 
tea  with  milk. 

^-th  Diet. — Fried  chicken,  fried  squab,  roast  venison, 
guinea  hen,  roast  beef  (cold),  roast  veal  (leg,  saddle), 
boiled  pike,  macaroni,  rice  pap,  finely  chopped  spinach, 
asparagus,  stewed  apples. 

This  table  has  been  verified  by  the  above-mentioned 
Penzoldt's  investigations.  All  these  experiments, 
however,  only  show  what  food  remains  in  the  stomach 
the  shortest  time.  This  would  perhaps  give  reason  for 
inferring  what  food  may  be  easily  digested  as  far  as 
the  stomach  is  concerned,  but  not  what  is  more  easily 
digested  as  a  whole,  i.e.,  made  use  of  for  the  economy 
of  the  body  with  the  smallest  amount  of  work.  The 
digestibility  of  food  substances  depends  firstly  upon 
their  shape  and  quality  ;  secondly,  upon  their  per- 
centage of  convertible  material. 


112  DISEASES    OF   THE    STOMACH. 

"Corpora  non  agunt  nisi  fluida,*'  is  an  old,  vvell- 
known  axiom.  Following  this  law  one  could  arrange 
the  following  scale  of  digestibility,  which  is  con- 
structed according  to  the  different  physical  conditions 
of  the  food : 

1.  Food  in  liquid  form  :  (a)  Liquid  at  ordinary 
temperature — milk,  meat  juice,  beef  tea,  bouillon,  pep- 
tone or  sarcopeptone dissolved  in  water,  bread  water,' 
strained  barley,  oatmeal,  rice  "water,  strained  oyster 
soup,  egg-albumin  water;  (b)  liquid  at  the  body  tem- 
perature— jellies,  fruit  jelly,  calf's-foot  jelly,  ice- 
cream, water-ice. 

2.  Pulpy  form.  The  food  is  mechanically  converted 
into  very  minute  particles  and  well  mixed  in  liquid — 
pap  soups  (barley,  oatmeal,  farina,  rice,  sago) ;  egg  in 
bouillon ;  Leube's  meat  solution,  pulverized  meat,  pul- 
verized crackers  in  milk,  water,  or  bouillon ;  butter- 
milk, kumyss,  cream,  butter. 

3.  Food  which  by  slight  trituration  iu  fluids  separ- 
ates into  minute  particles  :  White  bread  in  milk  or 
water  ;  the  tips  of  well-boiled  asparagus;  carrots, 
mashed  potatoes,  baked  potatoes  ;  the  yolk  of  hard- 
boiled  eggs  ;  oysters  (raw). 

4.  Solid  food.  White  bread,  rye  bread  ;  meat, 
hard-boiled  eggs,  fish,  cheese. 

5.  Substances  not  easily  digested.  Meat  with  tough 
fibre  ;  lobster  ;  sausages  and  Swiss  cheese  on  account 
of  their  solidity  ;  all  substances  containing  much  cellu- 
lose, principally  when  eaten  raw  ;  cold  slaw ;  all  salads, 

'  Bread  watpr.  Stale  bread  is  cut  into  slices  and  put  in  water  at 
temperature  of  room  for  from  two  to  three  hours,  then  the  water  is 
strained. 


DIET.  113 

cucumbers,  pickles,  raw  fruit,  apples,   pears,   pineap-. 
pie;  fruit  which  contains  much  acid,  therefore  all  un- 
ripe fruit,  strawberries;  substances  containing  much 
sulphur  and  forming  gases  in  the  intestines :  all  kinds 
of  cabbage,  principally  white  cabbage ;  beans. 

This  theoretically  constructed  scale  of  the  digestibil- 
ity of  food  is,  at  the  same  time,  in  the  main  points, 
similar  to  the  one  which  has  long  stood  the  test  of 
empiricism  and  which  I  ordinarily  employ  in  my 
practice. 

Dietetics  in  Acute  Diseases  of  the  Stomach. 

Acute  Gastric  Catarrh.  ■ — The  principle  of  rest  here 
occupies  the  first  place.  In  acute  gastric  catarrh,  dur- 
ing the  first  two  or  three  days,  in  which,  as  a  rule, 
there  is  a  total  loss  of  appetite,  only  very  little  nourish- 
ment in  liquid  form  should  be  given,  containing  princi- 
pally amjdacea,  barley  or  oatmeal  soup,  bouillon,  weak 
tea,  water.  As  a  rule,  one  must  not  force  a  patient  to 
take  food  during  the  first  or  even  during  the  second  day 
of  sickness.  The  anorexia  in  these  conditions  is  a  wise 
arrangement  made  by  nature  in  order  to  give  the  stom- 
ach rest.  If  there  is  thirst,  beverages  may  betaken  in 
small  quantities,  and  must  be  neither  very  cold  nor 
very  warm.  As  soon  as  the  appetite  reappears  one 
may  give  some  toasted  bread  or  zwieback,  milk,  soft- 
boiled  eggs  or  oysters,  permitting  after  a  while  small 
quantities  of  bread  and  meat,  and  then  passing  slowly 
to  the  ordinary  diet. 

Ulcer  of  the  Stomach. — During  the  rest  cure  of  von 
Ziemssen-Leube  give  liquid  diet,  consisting  principally 


114  DISEASES   OF   THE   STOMACH. 

of  milk,  for  two  or  three  weeks.  As  is  well  knowu, 
Cruveilhier  '  first  recommended  milk  for  the  purpose, 
and  even  now  there  are  some  physicians  who  limit 
themselves  to  milk  alone.  As  a  rule,  however,  it  is 
appropriate  to  allow,  besides  milk,  milk  in  combina- 
tion with  barley,  oatmeal,  or  rice  water.  In  addition 
to  this,  the  different  peptone  preparations  are  here  in 
place.  I  administer  Rudisch's  sarcopeptone,  manu- 
factured in  this  country,  on  account  of  its  being  pala- 
table and  highly  nourishing.  (The  Rudisch's  sarco- 
peptone contains  forty  per  cent  of  nitrogenous  sub- 
stances, including  twenty  per  cent  of  peptones.) 

One  may  give  most  appropriately  every  three  hours 
one  to  two  cupfuls  of  milk  with  the  addition  of  the 
above-named  decoctions  (four  times  daily)  and  sarco- 
peptone (twice  daily).  The  patient  must  not  drink 
these  fluids,  but  eat  them  with  a  spoon.  In  case  of 
hemorrhage  of  the  stomach  during  the  first  three  or 
four  days,  it  is  not  permitted  to  give  any  food  whatever 
by  the  mouth  ;  instead,  the  patient  must  be  fed  by  the 
rectum.  Ewald  has  proven  that  the  large  intestine  has 
the  ability  of  digesting  and  absorbing  albuminates 
even  without  special  previous  preparation ;  therefore 
the  following  may  be  given  as  a  nutritive  enema : 

1.  Three  to  five  eggs  are  mixed  with  150  c.c.  of 
sugar  water  (30  gm.  of  grape  sugar  dissolved  in  150 
c.c.  of  water),  a  small  quantity  of  common  table  salt  is 
added,  and  the  whole  mixture  well  beaten  ;  one  may  add 
also  a  small  quantity  of  starch  solution  or  mucilage. 

2.  One-half  pint  of  milk  with  two  eggs  and  50  gm. 
of  grape  sugar  added. 

1  "  Anatomie  Pathol. , "  1829-35. 


DIET.  115 

3.  One  and  a  half  tablespoonfuls  of  Rudisch's  sarco- 
peptone  dissolved  in  a  cupful  of  water. 

The  food  enemata  have  to  be  given  three  or  four 
times  daily.  It  is  necessary  that  the  fluid  should  he 
at  the  temperature  of  the  blood,  and  that  it  should  be 
injected  by  means  of  a  fountain  syringe  and  a  soft- 
rubber  rectal  tube.  Each  time  before  giving  a  nour- 
ishing enema  a  cleansing  enema  of  250  c.c.  of  luke- 
warm water  has  to  be  administered,  in  order  thorough- 
ly to  cleanse  the  large  intestine  and  make  it  more  fit 
for  absorption.  In  order  to  facilitate  the  retention  of 
the  feeding  enema  W.  Gilman  Thompson  '  suggests  the 
following  procedure :  Upon  withdrawing  the  tube,  if 
there  is  danger  that  the  injection  will  not  be  retained, 
a  soft  compress  or  folded  towel  should  be  pressed  up 
firmly  against  the  anus  for  twenty  minutes  or  half  an 
hour.  In  case  of  thirst  the  patient  is  allowed  to  take 
small  pieces  of  ice  into  the  mouth  from  time  to  time. 
Thirst  and  hunger,  however,  may  be  entirely  re- 
lieved by  nutrient  enemata  alone.  "In  an  obstinate 
case  of  gastric  hemorrhage  in  which  absolutely  noth- 
ing, not  even  water,  was  given  by  the  mouth  for 
more  than  a  week,"  W.  Gilman  Thompson*  says,  "I 
questioned  the  patient  in  regard  to  her  sensations  of 
hunger  and  thirst,  and  she  told  me  that  they  were 
entirely  relieved  after  the  first  twenty-four  hours'  use 
of  nutrient  enemata.  The  mouth  and  tongue  were 
not  dry  and  she  did  not  lose  weight  during  this  period." 
Three  days  after  the  disappearance  of  blood  one  slowly 
and  cautiously  begins  the  liquid  diet. 

*  W.  Gilman  Thompson  :  "Practical  Dietetics,  with  Special  Ref- 
erence to  Diet  in  Disease,"  New  York,  1895. 
^  W.  Gilman  Thompson :  I.  c. 


116  DISEASES   OP   THE   STOMACH, 

Dietetics  in  Chronic  Affections  of  the  Stomach. 

While  in  acute  diseases  of  the  stomach  we  pay  most 
attention  to  giving  rest  to  the  organ — for  here  even  an 
insufficient  nutrition  and  the  loss  of  several  pounds  of 
bodily  weight  are  not  of  much  importance,  as  the  quick- 
ly recuperating  organism  replaces  the  losses  caused 
during  the  sickness  by  taking  increased  quantities  of 
food — in  the  chronic  affections  it  is  of  utmost  and  vital 
importance  to  see  that  sufficient  quantities  of  food  are 
taken. 

The  greatest  number  of  stomach  patients  consulting 
the  physician,  after  the  disease  has  been  progressing 
quite  a  while,  have  lost  more  or  less  weight.  The 
principal  reason  for  this  lies  in  the  fact  that  the  body 
has  received  too  small  a  quantity  of  nourishment  in 
order  to  replace  the  waste. 

The  ordinarily  insufficient  appetite,  the  early  appear- 
ance of  a  feeling  of  satiation,  the  pain  often  appearing 
after  meals,  and  less  frequently  vomiting,  are  the 
principal  factors  of  subnutrition. 

At  this  point  it  becomes  necessary  to  divide  the 
patients  with  stomach  troubles  into  two  large  classes: 

1.  Into  those  with  organic  lesions  of  the  stomach. 
2.   Into  those  with  functional  disturbances. 

The  first  class  comprises,  (a)  the  malignant  diseases 
of  the  stomach  itself  or  its  orifices  (carcinoma  ventric- 
uli,  cardise,  pylori) ;  (b)  cicatricial  strictures  of  the 
cardia  or  pylorus;  (c)  absence  of  secretory  work  of 
the  stomach :  achylia  gastrica. 

In  this  whole  first  class,  with  the  only  exception  of 
group  c,  which  lies,  so  to  speak,  between  the  first  and 


DIET.  117 

second  class,  we  are  unable  to  accomplish  much  either 
by  medicinal  treatment  or  dietetics.  In  existing  stric- 
tures of  the  cardia  or  pylorus  it  will  be  necessary  to 
seek  surgical  aid.  Even  in  cancer  of  the  stomach  wall 
the  resection  of  the  affected  part  is  advisable  when- 
ever the  operation  is  possible.  I  cannot  refrain  from 
calling  attention  at  this  place  to  the  splendid  results  of 
the  recent  stomach  surgery,  which  of  late  has  been 
frequently  practised  in  our  own  country  (F.  Lange,  N. 
Senn,  R.  Abbe,  Willy  Meyer,  McBurney,  Weir,  Bull, 
Gerster,  Roswell  Park,  Murphy,  and  others).  In  car- 
cinomatous strictures  a  new  passage  can  be  established, 
either  for  bringing  food  into  the  stomach,  by  a  gastric 
fistula,  or  for  allowing  it  to  pass  into  the  intestines,  by 
gastro-enterostomy.  In  this  way  we  succeed  at  least 
in  temporarily  giving  these  unfortunates  relief  and  in 
ameliorating  their  nutritive  condition.  In  the  cicatri- 
cial strictures  we  are  warranted  in  promising  to  the 
patients,  nowadays,  perfect  recovery  by  undergoing 
operative  treatment.  (In  strictures  of  the  cardia  a 
methodical  dilatation  with  bougies  may  sometimes 
also  suffice.)  The  pyloroplastic  operation  (of  Heincke- 
Mikulicz)  and  the  cardiotomy  or  cardio-fissure  (Abbe) 
belong  to  the  most  beautiful  and  blissful  operations 
which  have  ever  been  practised.  After  the  operation 
the  patients  are  enabled  to  eat  everything,  and  to  live 
without  any  trouble  whatever,  i.e.,  they  are  perfectly 
cured. 

Before  the  operations,  or  if  such  are  unfeasible,  one 
should  administer  light,  very  slightly  irritating  nour- 
ishment, and  always  endeavor  to  make  the  patient  par- 
take of  a  larger  quantity  of  food.     If  there  is  obsti- 


118  DISEASES   OF   THE   STOMACH. 

nate  and  constant  vomiting,  it  is  necessary  to  employ 
nutritive  enemata. 

Group  (c)  achylia  gastrica  will  be.  advantageously 
discussed  in  regard  to  diet  under  Class  2. 

The  second  class  of  functional  disturbances  includes 
the  largest  number  of  all  dyspeptics.  Here  stand 
uppermost  chronic  gastric  catarrh,  atony  of  the  stom- 
ach, dilatation  of  the  stomach,  gastroptosis,  snperacid- 
ity,  with  or  without  hypersecretion,  nervous  gastral- 
gia,  nervous  dyspepsia,  and  as  an  intermediary  between 
the  first  and  second  class,  achylia  gastrica. 

It  appears  advisable  to  discuss  first  the  whole  class, 
and  thereafter  to  give  special  rules  for  the  different 
groups.  Liquid  food  or  partly  predigested  substances 
(as  all  peptone  preparations)  are  not  in  place  here.  By 
making  the  stomach  work  too  little,  the  weakened 
condition  of  this  organ  is  retained  and  aggravated  in 
time.  We  must  always  bear  in  mind  the  principle  of 
strengthening  the  organ  by  means  of  appropriate 
work. 

A  well-known  clinician  is  said  to  express  himself  in 
his  lectures  in  the  following  way  regarding  the  dietet- 
ics of  the  dyspejDtic : 

When  a  dyspeptic  patient  asks  you  the  question, 
"What  shall  I  eat?"  reply,  "Eat  what  you  like."  If 
he  asks,  "How  much  shall  I  eat?"  say  to  him,  "Eat  as 
much  as  your  appetite  demands."  If  he  still  asks, 
"When  shall  I  eat?"  answer,  "Eat  when  you  are 
hungry." 

Although  I  do  not  favor  strict  and  severe  dietetic 
rules,  nevertheless  I  deem  the  above-mentioned  re- 
marks as  going  too  far.     Unlike  the  normal  healthy 


DIET. 


119 


condition,  in  which  instinct  shows  us  the  right  meas- 
ure to  eat,  neither  too  little  nor  too  much,  stomach 
patients  very  often  have  lost  the  feeling  of  self-regula- 
tion, and  as  a  rule  partake  of  too  small  quantities  of 
food.  (Only  in  a  few  cases  of  bulimia  there  may  be 
an  increased  desire  for  food,  and  in  connection  with  it 
the  quantity  of  food  taken  may  sometimes  be  too  large.) 
It  is  therefore  necessary  to  instruct  the  patients  to  eat 
more,  or  to  give  them  exact  figures  of  the  quantity  of 
food  required.  As  this  varies  with  every  individual  it 
is  most  practicable  to  let  the  patient  weigh  himself 
once  a  week  and  to  see  whether  he  keeps  his  weight. 
If  the  patient  does  not  lose  any  it  is  the  best  sign  that 
he  takes  sufficient  nourishment.  As  good  instances 
of  a  sufficient  amount  of  food  contained  in  the  diet 
we  give  the  following  bills  of  fare  which  have  been 
suggested  by  C.  von  Noorden : ' 


I.  A  Principally  Milk  Diet  with  Addition  of  Carbohydrates 
IN  Liquid  Form. 


Albumin, 
per  cent. 

Fat, 
per  cent. 

Carbo- 
hydrate, 
per  cent. 

Calories, 
per  100. 

Milk,  1,700  cc 

70.2 
10 

7.0 

66.3 
5.0 

69.7 
30 

40 

1295 

Soup  of  tapioca  flour,  30  gm.  and 
10  gm.  alburaose.'^ 

164 

Soup  of  40  gm.  wheat  flour,  with 
some  of  the  milk,  10  gm.  sugar 
and  one  ess 

244 

Total 

87.3 

71.8 

139.7 

1703 

» C.  von  Noorden :  Beii.  Klinik,  1838,  J.  55. 

^  10  gm.  albumose  is  contained  in  90  cc.  of  Denayer's  peptone 
preparation  or  in  22  of  Kemmerich's  or  in  30  of  Koch's. 


120 


DISEASES    OF   THE    STOMACH. 


II.  Principally    Milk    Diet    with    the    Addition    of    Carbo- 
hydrates AND  Fat  in  Pap  Form  and  Soups. 


Albumin, 
per  cent. 

Fat, 
per  ceut. 

Carbo- 
hydrates, 
per  cent. 

Calories, 
per  lUO. 

Milk,  1,500  c.c 

63 
17 

7 

58.5 
13.5 

5.5 

63 

15 

90 

1056 

Soup  of    15    gni.   sago,    10  gm. 

butter,    one    egg,    10    gm.    al- 

bumose. 
Pap  of  80  gm.  corn  flour,  one  egg, 

10  gm.  sugar  (two  meals) . 

257 
398 

Total 

86 

77.5 

168 

1711 

III.  Milk  Diet  with  Addition  of  Light  Pastry  and  Broths. 


Albumin, 
per  cent. 

Fat, 
per  cent. 

Carbo- 
hydrates, 
per  cent. 

Calories, 
per  100. 

Milk,  1,250  cc 

51 
10 

5 

7 

49 

14 

12 
14 

52 
30 

50 
30 

878 

Meat  broth  with  one  egg,  10  gm. 

of  butter,  50  gm.  of  fine  toasted 

wheat  bread. 

Cakes  70  gm. ,  butter  15  gm 

Soup  of  30  gm.  tapioca  flour,  oue 

egg,  10  gm.  butter. 

294 

337 

282 

Total 

73 

89 

162 

1791 

IV.    Milk  with  Tender  Meat,  Pastry,  Butter,  and  Soups. 


Spring  chicken,  100  gm 

Mashed  potatoes,  100  gm 

Two  eggs 

Toasted  wheat  bread,  100  gm. . . . 

Butter,  30  gm 

Trout,  100  gm 

Milk,  1250  cc 

Total 


Albumin, 
per  cent. 


19.6 

2.0 

14.1 

7 

19.3 
51 


113.0 


Fat, 
per  cent. 


2.8 

4.0 
11.0 

0.5 
23.0 

2.1 
49 


92.4 


Carbo- 
hydrates, 
per  cent. 


20 
55' 

52 


127 


Calories, 
per  100. 


106.4 
127.4 
160.1 
258.8 
213.9 
106.4 


1851 


DIET. 

V.  EiCH,  NOT  Ieritating  Diet. 


131 


Tender  meat, '  250  gm. 

Cacao,  20  gm 

Three  eggs 

100  gm.  Zwieback 

wheat  bread. . 

cakes  

butter 

tapioca  flour  . 

corn  flour  . . . . 


100 
50 
50 
40 
40 
20 


sugar 


1250  CO.  milk 


Total 144 


Albumin, 
per  cent. 


49 
4 

21 
8 

7 
4 


51 


Fat, 
per  cent. 


7.0 
6.0 

16.0 
1.0 
0.5 
2.3 

44.0 


49 


126.0 


Carbo- 
hydrates, 
per  cent. 


75 
55 
36 

'46' 
40 
20 
52 


318 


Calories, 
per  100. 


266 
105 
235 
259 

'187 
407 
164 

164 

82 
878 


2747 


Besides  the  importance  of  a  sufficient  diet,  we  must 
remind  patients  to  lead  a  regular  life,  to  eat  slowly 
(how  many,  especially  in  our  country,  sin  against  this 
natural  law!),  and  to  chew  well  and  triturate  the 
food.  One  must  avoid  either  extremely  cold  or  ex- 
tremely warm  food.  Too  copious  and  too  complicated 
meals  must  be  strongly  forbidden. 

I  have  made  it  a  rule  not  to  forbid  anything,  except 
what  is,  according  to  my  conviction,  obnoxious  in  the 
given  case.  In  this  way  the  patients  have  a  great 
variety  in  their  food  and  run  less  risk  of  subnutrition. 
Likewise  we  need  not  change  the  number  of  meals  nor 
the  hours  appointed  unless  there  should  be  especial 
indications  for  such  a  proceeding. 

Among  the  laity,  as  well  as  often  among  medical 
men,  there  are  prejudices  against  certain  forms  of 
food.  Thus,  for  instance,  until  recently  it  was  cus- 
tomary to  forbid  all  kinds  of  fat,  even  butter,  in  all 


'  Meat  of  various  kinds,  finely  chopped,  raw  or  fried  in  butter  ; 
cold  or  warm,  taken  at  two  meals. 


122  DISEASES   OF   THE    STOMACH. 

dyspeptic  conditions.  Fat,  however,  belongs  to  the 
grouj)  of  food-stuffs  which  has  the  largest  number  of 
heat  units,  and  besides,  is  not  bulky  as  a  nourishment 
(butter).  Undecomposed  fat  passes  the  stomach  with- 
out molesting  the  latter,  and  is  digested  in  the  small 
intestines.  There  is,  therefore,  no  reason  for  forbid- 
ding butter,  which  should,  on  the  contrary,  be  highly 
recommended.  Fearing  fermentative  processes  the 
partaking  of  bread  and  other  food  rich  in  carbohy- 
drates is  very  often  greatly  limited,  or  even  totally 
forbidden.  Although  it  is  true  that  the  carbohydrates 
easily  undergo  fermentative  processes,  those  cases, 
however,  in  wiiich  considerable  fermentations  exist  in 
the  stomach  are  quite  rare,  and  as  a  rule  are  found 
only  where  there  is  considerable  stagnation  of  food  in 
the  stomach.  In  these  cases,  to  be  certain,  a  diet  con- 
sisting princij)ally  of  animal  albumin  (meat)  for  a 
short  period  is  very  useful.  By  means  of  lavage  of 
the  stomach  and  other  appropriate  treatment  we  soon 
succeed  in  checking  the  fermentative  processes,  and 
carbohydrates  can  then  be  administered. 

An  adult,  according  to  Koenig,'  daily  consumes  -J- 
to  f  kgm.  of  bread ;  fifty  to  sixty  per  cent  of  the  total 
food  substances,  and  fifty  to  seventy-five  per  cent  of 
the  carbohydrates  are  taken  in  the  form  of  bread. 
This  clearly  shows  the  important  part  bread  takes  in 
diet.  Its  use  is,  therefore,  as  a  rule  advisable.  It  is 
ordinarily  said  that  crust  of  bread,  stale  bread,  and 
zwieback  are  easier  to  digest,  on  account  of  the  starch 
contained  in  them  being  largely  converted  into  dex- 

'  Koenig ;  "Die  meuschliclien  Nahrungs-  nnd  Genussmittel, " 
Berlin,  1883,  p.  430. 


DIET,  123 

trose.  Although  I  am  of  the  opinion  that  too  fresh 
bread  must  be  avoided,  I  nevertheless  rarely  find 
much  difference  in  the  digestibility  of  the  crust  or 
other  parts  of  well-baked  fine  white  bread,  judging 
from  experience  gained  from  my  own  patients. 

Articles  of  luxury  (wine,  beer,  coffee,  tea)  are,  as  a 
rule,  permissible.  It  is,  however,  necessary  to  give 
them  in  small  amounts  and  in  appropriate  form. 
Strong  liquors  must  be  avoided,  likewise  all  strong 
spices. 

Appetizers,  as  a  small  amount  of  caviare,  sardellen, 
or  anchovies,  on  a  small  slice  of  bread  or  cracker, 
taken  one-quarter  of  an  hour  before  the  meal,  are  not 
only  allowed  but  frequently  directly  commendable. 

In  reference  to  the  special  rules  for  the  different  dis- 
eases of  the  second  class,  v/e  shall  have  at  times  to  re- 
duce the  quantity  of  meat  taken  in  all  conditions  ac- 
companied by  a  diminished  secretion  of  hydrochloric 
acid  (gastritis  chronica  glandularis,  atony  -j-  subacid- 
ity) ;  on  the  other  hand,  the  quantity  of  richly  carbo- 
hydrate vegetable  food  must  be  increased.  Kumyss, 
matzoon,  milk  with  cognac  (7  to  10  c.c.  of  cognac  to 
200  or  250  c.c.  of  milk)  may  be  taken  with  crackers 
either  during  or  between  meals. 

In  all  the  conditions  attended  with  superacidity  the 
quantity  of  albuminous  food  should  be  increased  ;  here 
one  may  give  a  great  deal  of  meat  (venison  included). 
In  superacidity  with  hypersecretion  frequent  and  small 
meals  containing  consistent  food  are  most  appropriate. 
If  there  is  a  feeling  of  hunger  between  meals,  the 
white  part  of  hard-boiled  eggs  may  be  taken  (as  is  well 
known,   albumin   combines  with   acid  and  makes  it, 


124  DISEASES   OF   THE   STOMACH. 

SO  to  say,  inert).  The  quantity  of  beverages  must  be 
greatly  limited ;  most  suitable  in  this  instance  are 
small  quantities  of  Vichy  water.  In  dilatation  of  the 
stomach  and  in  gastroptosis  it  is  also  advisable  to  give 
small  and  frequent  meals,  and  to  restrict  the  quantity 
of  liquids  taken.  As  a  rule,  milk  and  beer  do  not 
agree  well  in  these  cases.  Small  quantities  of  wine 
or  imported  dark  beer  or  porter  may  be  allowed. 

In  nervous  dyspepsia  and  gastralgia  our  main  object 
will  be  to  systematically  increase  the  quantity  of  food 
— here  milk  and  its  derivatives  (koumyss,  matzoon, 
bonny-clabber,  buttermilk,  cream)  taken  between 
meals  play  a  great  part  (Weir  Mitchell  treatment). 

In  achylia  gastrica  it  is  of  utmost  importance  to 
give  liquid  or  very  well  triturated  (pulverized)  food. 
For  here  the  chemical  action  of  the  stomach  has  entire- 
ly ceased,  and  vegetable  (on  account  of  the  albumin- 
ous membrane  enclosing  the  starch  granules)  as  well 
as  animal  food  pass  from  the  stomach  unchanged,  and 
not  converted  into  small  particles,  into  the  intestines 
and  irritate  them,  unless  there  has  long  been  formed 
a  sufficient  adaptation  for  these  conditions.  Vege- 
table food,  on  account  of  its  containing  chiefly  carbo- 
hydrates, will  be  predominant  in  the  diet  of  this  affec- 
tion. Thus  achylia  gastrica,  in  reference  to  diet, 
stands  midway  between  the  first  and  second  classes. 
It  approximates  the  first  class  in  so  far  that  it  neces- 
sitates a  liquid  or  mechanically  minutely  triturated  or 
pulverized  food,  the  second  class  in  allowing  a  richly 
carbohydrate  diet. 

Some  readers  may  miss  exact  bills  of  fare  for  chronic 
affections  of  the  stomach.     They  have  been  omitted, 


DIET.  125 

as  it  is  always  necessary  to  individualize,  especially  in 
diet.  We  must  guide  ourselves  more  by  the  patients 
than  by  theoretical  conclusions.  Our  main  object 
must  be  to  care  for  a  sufficient  nutrition.  Only  the 
above-given  principal  rules  on  diet  must  be  observed, 
although  at  times  even  they  have  to  be  modified.  In 
reference  to  this  point  Hippocrates*  said:  ''' Dandum 
aliquid  tempori,  regioni,  wtati  et  consuetudini.^'* 

At  present,  with  our  more  exact  knowledge,  we 
have  come  to  appreciate  this  conclusion  to  a  still 
greater  degree. 

^  Cited  from  Muuk  and  UfCelmauu,  loc.  cit. ,  p.  430. 


CHAPTER   IV. 

LOCAL  TREATMENT  OF  THE  STOMACH. 

1.  Lavage. 

Gastric  lavage,  which  is  so  frequently  employed  in 
the  treatment  of  diseases  of  the  stomach  at  the  pres- 
ent day,  was  first  introduced  by  Kussmaul '  in  1S67, 
who  used  for  this  purpose  the  stomach  pump.  Pre- 
vious to  that  time  this  method  had  been  practised 
by  Bush,  Arnott,  Sommerville,  and  Blutin/  but  to 
Kussmaul  belongs  the  credit  of  em^jloying  it  in  a 
rational  and  scientific  manner.  The  illustration  (Fig. 
33)  affords  an  idea  of  the  mechanism  of  the  instru- 
ment employed  by  the  latter  observer  which,  however, 
is  now  only  of  historical  interest,  since  it  has  been 
supplanted  by  simpler  apparatuses  based  upon  the 
principle  of  siphonage. 

(a)  Funnel  Arrangement.  The  one  that  is  most 
commonly  in  use  consists  of  a  glass  funnel  attached  to 
a  piece  of  soft-rubber  tubing  of  about  one  yard  in  length 
which  can  be  slipped  over  the  upper  end  (connecting 
glass  tube)  of  the  stomach  tube.  By  filling  the  funnel 
with  water,  and  alternately  raising  and  lowering  the 
same,  the  stomach  may  be  filled  or  emptied.     The  fun- 

'  Kussmaul :  "  Ueber  die  Behandlung  der  JIagenerweiterung  durch 
eine  neue  Methode  raittelst  der  Magenpumpe. "  Deutsches  Archiv  f. 
klin.  Med.,  vol.  vi.,  p.  4oo. 

2  See  Ewald :  "  The  Diseases  of  the  Stomach, "  New  York,  1892, 
p.  5. 


LOCAL   TREATMENT   OF   THE   STOMACH. 


127 


nel,  as  a  rule,  is  not  very  large  and  has  a  capacity  of 
about  300  to  500  c.c.  Ewald  *  advises  the  use  of  a 
very  large  funnel  of  about  two  quarts  capacity.  This 
rests  in  a  wooden  frame  on  the  floor  and  after  being 
filled  with  the  requisite  amount  of  water  is  then  raised 
to  a  height  suitable  to  obtain  the  amount  of  pressure 
desired.  The  water  escapes  from  the  various  open- 
ings in  the  tube  as  from  a  sprinkler,  and  the  stomach 
is  in  this  way  irrigated.     To  siphon  the  water  out  of 


Fig.  3-3. — ^Kussmaul's  Stomach  Pump. 


the  stomach,  the  funnel  is  again  placed  in  the  wooden 
frame,  and  thus  the  fluids  of  the  stomach  return. 
Here  the  whole  quantity  of  the  wash-water  can  be 
easily  inspected. 

(6)  Leube-JRosenthal  Apparatus.  The  raising  of  the 
big  funnel  is  quite  troublesome,  and  I  therefore  prefer 
to  use  in  my  own  practice  the  Leube-Rosenthal  ap- 
paratus which  I  consider  the  best  means  of  washing 
out  the  stomach   (see  Fig.    34).      This  consists  of   a 

'C.  A.  Ewald,  I.  c.  v.  64. 


128 


DISEASES    OF    THE    STOMACH. 


large  glass  irrigator  of  about  two  to  three  quarts  ca- 
pacit3\  Leading  from  the  irrigator  a  large  piece  of 
Boft-rubber  tube  is  connected  by  means  of  a  Y-shaped 


Fig.  34.— Leube-Rosenthal  Apparatus  for  Gastric  Lavage. 

glass  tube  first  with  the  stomach  tube,  secondly,  witn 
another  quite  long  piece  of  soft-rubber  tubing.  Botn 
arms  of  tubing,  the  one  running  from  the  irrigator 
the   other   into  a  waste    vessel,    are   provided    with 


LOCAL    TREATMENT    OP    THE    STOMACH.  129 

clamps.  By  opening  the  clamp  on  the  irrigator  tub- 
ing, the  water  runs  into  the  stomach.  By  closing  the 
same  and  opening  the  tube  running  to  the  waste  ves- 
sel, the  water  is  withdrawn  from  the  stomach.  The 
amount  of  water  which  is  used  for  each  single  filling 
of  the  stomach  may  vary  from  400  c.c.  to  a  litre. 
The  stomach  may  be  filled  with  water  so  long  as  the 
patient  does  not  experience  any  pressure.  As  soon  as 
he  begins  to  feel  some  pressure,  the  quantity  should 
not  be  increased,  but  at  once  withdrawn.  This  man- 
oeuvre can  be  repeated  twice  or  three  times  at  each  sit- 
ting. In  case  large  quantities  of  mucus  are  present 
in  the  wash-water,  it  is  best  to  have  the  patient  shake 
himself,  especially  his  abdomen,  while  the  water  is 
entering  the  stomach.  In  this  way  it  is  possible  to 
mechanically  clean  the  organ  much  more  thoroughl}' 
than  would  otherwise  be  the  case.  The  same  method 
of  shaking  has  to  be  applied  if  the  stomach  contains 
some  food. 

The  advantages  of  this  apparatus  are  quite  mani- 
fold: 

1.  The  ease  with  which  the  whole  procedure  can  be 
executed. 

2.  The  water  introduced  into  the  stomach  is  always 
clear,  as  the  waste  water  passes  through  a  separate 
tube ;  while  in  the  use  of  the  funnel  arrangement  after 
the  first  filling  the  funnel  and  the  tubing  become 
soiled  during  the  withdrawal  of  the  contents,  and  in 
consequence  of  this,  during  the  second  filling,  much  of 
the  mucus  which  has  remained  within  the  apparatus 
returns  to  the  stomach. 

(c)  Friedlieb's  Apparatus.     Another  very  suitable 


130 


DISEASES    OF   THE    STOMACH. 


arrangement  for  washing  out  the  stomach,  especially  if 
the  patient  has  to  perform  the  procedure  himself,  is  an 
apparatus  that  has  been  in  use  in  this  country  for  many 
years,  and  is  similar  to  the  one  described  by  Friedlieb.' 
It  consists  of  a  long  piece  of  soft-rubber  tubing  of  about 
two  yards  in  length,  the  middle  of  which  is  expanded 
into  a  bulb.     The  stomach  end  of  the  tube  is  provided 

with  two  big  openings,  while 
the  other  is  shaped  into  a 
funnel  (see  Fig.  35). 

In  the  withdrawal  of  the 
gastric  contents  with  this 
a^jparatus  the  tube  should 
be  closed  with  two  fingers 
at  a  point  situated  between 
the  bulb  and  the  lips  of  the 
patient.  If  the  bulb  is  now 
compressed,  and  the  two  fin- 
gers applied  to  its  distal  side, 
then  on  relaxing  the  pres- 
sure on  the  bulb  it  will  become  filled  with  stomach 
contents.  By  again  closing  the  upper  end  of  the 
tube  and  compressing  the  bulb,  the  contents  will 
flow  out  from  the  apparatus.  In  this  way  the  con- 
tents of  the  stomach  can  be  removed.  The  wash- 
ing of  the  organ  is  now  executed  in  the  usual  way  by 
filling  the  funnel  end  with  water,  raising  the  same 
and  lowering  again.  The  bulb  then  need  not  be  com- 
pressed if  the  water  flows  out  easily.  If  the  stream 
of  water  stops  flowing  before  the  entire  quantity  has 
left  the  stomach,  then  suction  by  means  of  the  bulb 

'Friedlieb:  Deutsche  med.  Woclienschrift,  1893,  No.  51. 


Fig. 


35.— Friedlieb's    Apparatus 
for  Gastric  Lavage. 


LOCAL   TREATMENT    OF    THE    STOMACH.  131 

must  be  performed  as  above  described.  Instead  of 
using  the  fingers  in  order  to  compress  the  tube,  two, 
clamps  on  both  sides  of  the  bulb  may  serve  the  same 
purpose. 

{d)  Several  writers  have  tried  to  wash  out  the  stom- 
ach by  means  of  a  tube  d  double  courant.  Very  re- 
cently J.  C.  Hemmeter^  in  this  country  anew  devised 
such  an  apparatus  for  this  purpose.  According  to  my 
opinion,  however,  all  these  devices  are  unnecessary. 
Lavage  of  the  organ  cannot  be  accomplished  more 
thoroughly  by  means  of  these  than  by  the  three  above- 
described  simple  apparatuses. 

A  Few  Rules  Concerning  the  Application  of  Lavage. 

The  introduction  of  the  tube  has  to  be  performed  as 
above  stated,  when  we  spoke  of  the  introduction  of 
the  tube  for  the  withdrawal  of  gastric  contents  for  ex- 
amination. During  the  introduction  of  the  tube,  it  is 
necessary  to  have  the  patient  hold  his  head  slightly 
bent  forward  (as  a  rule,  patients  try  to  throw  their 
heads  far  back,  which  is  a  great  obstacle  to  the  en- 
trance of  the  tube  into  the  oesophagus).  The  insertion 
of  the  tube  has  to  be  done  quite  rapidly.  During  the 
entire  procedure  it  is  best  to  have  the  patient  breathe 
deeply.  It  is  furthermore  of  importance  to  hold  the 
tube  with  the  hand  not  far  from  the  mouth  of  the  pa- 
tient in  order  that  the  apparatus  may  not  move  up  and 
down  and  in  this  way  cause  irritation  of  the  stomach 
and  produce  nausea  and  spells  of  vomiting.  In  case 
the  outflow  of  the  fluid  is  suddenly  arrested  (by 
food  particles  obstructing  the  opening  of  the  tube),  a 

'  J.  C.  Hemmeter  :  New  York  Medical  Journal,  March  30th,  1895. 


132  DISEASES    OF    THE    STOMACH. 

small  quantity  of  water  has  to  be  poured  in  again, 
and  the  siphoning  repeated.  How  long  and  how  often 
the  stomach  should  be  washed  out  is  difficult  to  define. 
As  a  rule,  this  procedure  should  be  kept  up  until  the 
water  returns  quite  clear.  The  appearance  of  blood 
in  the  wash-water  necessitates  the  withdrawal  of  the 
tubing.  If,  however,  only  a  few  blood  stains  are  visi- 
ble in  the  water,  they  are  of  no  import,  and  the  lavage 
can  be  continued. 

Indications. 

Aside  from  diagnostic  purposes  lavage  must  be  per- 
formed (1)  when  there  is  stagnation  of  food  in  the 
stomach ;  (2)  whenever  large  quantities  of  mucus  are 
present  in  the  organ. 

Contra-indications. 

These  comprise  all  conditions  in  which  introduction 
of  the  tube  is  not  permissible,  as  for  instance,  hemor- 
rhages, ulcer  of  the  stomach,  etc. 

2.  The  Gastric  Douche  {Malhranc) .* 

By  the  gastric  douche  is  meant  a  sprinkling  of  the 
stomach  with  water  under  high  pressure.  This  can  be 
done  by  raising  the  funnel  of  the  washing  apparatus 
to  a  considerable  height.  Ewald's  tube,  which  has 
several  small  openings  and  one  large  one,  is  most  suit- 
able for  this  purpose.  Eosenheim "  likewise  makes  use 
of  a  similar  tube.  Boas  employs  a  tube  with  many 
small  openings  of  pinhead  size.     The  latter,  however, 

'  Malbranc :  Bevl.  klin.  Wonhenschr. ,  1878,  No.  4. 
*Th.     Rosenheim:    "Ueber  die  Magendouche."    Therapeutische 
Monatshefte.  1892. 


LOCAL    TREATMENT    OF    THE    STOMACH.  133 

has  the  disadvantage  that  the  water  cannot  return 
quickly.  The  gastric  douche  was  applied  by  Malbranc 
and  afterward  by  the  above-named  writers  in  order  to 
combat  severe  gastralgias. 

According  to  my  experience  there  is  but  little  differ- 
ence between  lavage  and  douching  of  the  stomach.  In 
fact,  every  form  of  lavage  has  almost  the  same  effect 
as  the  gastric  douche.  Of  late  M.  Gross/  of  New 
York,  has  devised  a  double-current  gastric  douche. 

Both  lavage  and  the  gastric  douche  have  been  made 
use  of  for  the  application  of  medicaments  directly  to 
the  mucous  membrane  of  the  stomach.  Thus,  for  in- 
stance, various  antiseptic  solutions  have  been  applied 
(boracic  acid,  salicylic  acid,  sodium  salicylate,  thymol, 
creolin,  lysol,  etc.).  Again,  chloride  of  sodium  on  the 
one  hand,  and  nitrate  of  silver  on  the  other  (the  one 
to  increase,  the  other  to  diminish  gastric  section)  have 
been  used  by  Boas  and  Eosenheim,^ 

The  solution  introduced  into  the  stomach  by  means 
of  the  apparatus  is  left  there  for  a  few  minutes  (two 
to  five)  and  then  withdrawn.  This  procedure  has  the 
great  disadvantage  that  in  order  to  apply  a  solution  in 
the  right  concentration,  covering  the  whole  inside  of 
the  stomach,  a  considerable  quantity  of  the  medica- 
ment is  absolutely  necessary.  The  quantity  of  the 
agent  has  to  exceed  the  normal  dose,  and  reach  the 
poisonous  limit.  Although  by  emptying  we  certainly 
remove  the  greatest  part  of  the  solution  and  in  this 
way  the  danger  of  intoxication  is  greatly  diminished, 
nevertheless  a  considerable  quantity  of  the  injected 

'  M.  Gross  ;  Medical  Record,  1895. 
^  Rosenheim  :  L.  c. 


134  DISEASES    OF   THE    STOMACH. 

fluid  may  pass  through  the  pylorus  into  the  intestines 
beyond  our  control  and  at  times  may  do  harm.  That 
is  the  reason  why  nitrate  of  silver  and  similar  poison- 
ous substances  should  not  be  introduced  into  the 
stomach  by  these  means. 

3.  The  Gastric  Spray  {EinJwrn). 

In  cases  in  which  it  is  necessary  to  apply  medica- 
ments of  a  toxic  or  irritating  character  to  the  gastric 
mucosa,  the  risk  of  poisonous  effect  can  be  prevented  by 
the  use  of  the  spray,  by  means  of  which  large  sur- 
faces can  be  covered  with  a  comparatively  small 
amount  of  fluid. 

In  order  to  make  use  of  the  spray  in  diseases  of  the 
stomach,  the  usual  spray  apparatus  has  been  modified 
by  me  in  such  a  way  that,  instead  of  the  hard -rubber 
branch  of  the  apparatus,  the  same  branch  is  made  of 
soft-rubber  and  lengthened.  In  this  way  the  gastric 
spray  apparatus  consists  of  the  usual  spray  apparatus, 
in  which  there  is  a  soft  Nelaton  tube,  of  TO  cm. 
length,  inserted  between  the  nozzle  and  the  hard-rub- 
ber branch  running  to  the  bottle;  within  the  Xelaton 
tubing,  another  soft  tube  of  thinner  calibre  connects 
the  inner  capillary  tube  with  the  nozzle  (see  Fig.  Sfi).' 

As  the  spray  is  generated  by  the  air  forced  by  the 
bulb  through  the  tube,  taking  up  the  fluid  and  divid- 
ing it  into  fine  particles,  the  medicament  will  neces- 
sarily come  in  contact  with  every  part  touched  by  the 
air. 

'  Max  Einhorn  :  "The  Use  of  the  Spray  in  Diseases  of  the  Stom- 
ach."    New  York  Medical  Journal,  September  ITth,  1892. 

-The  gastric  spray  apparatus  is  maDufactured  by  J.  Reynders  «fc 
Co..  303  Fourth  Avenue,  New  York. 


LOCAL    TREATMENT    OF   THE    STOMACH. 


135 


If  the  stomach  is  empty  when  spraying,  the  air  that 
enters  will  expand  the  organ  and  transport  the  fluid  to 
every  part  of  its  interior. 

The  administration  of  the  spray  in  gastrotherapeusis 
is  a  suitable  form  for  fulfilling  the  following  purposes: 

1,  To  disinfect  the  mucous  membrane  of  the  stom- 
ach. 

2.  To  exert  an  astringent  effect. 


Fig.  36. — The  Gastric  Spray  Apparatus  (Einhorn). 


3.  To  produce  analgesia  in  gastralgia  of  local  char- 
acter (from  ulcer,  cicatrix,  or  cancer). 

Method. — As  it  is  possible  to  spray  the  stomach  only 
in  its  empty  state,  it  will  be  necessary  to  administer  the 
spray  either  when  fasting  or  after  a  previous  lavage. 

A  preceding  lavage  will  always  be  indicated  if  we 
intend  to  disinfect  or  apply  astringents,  for  in  these 
instances  it  is  necessary  first  to  remove  the  mucus  with 
the  micro-organisms  embedded  therein.  In  order  to 
exert  an  analgesic  influence,  the  lavage  may  perhaps 
be  omitted. 

After  filling  the  apparatus  with  a  sufficient  amount 


136  DISEASES    OF   THE    STOMACH. 

of  the  required  solution,  the  tube  end  is  dipped  into 
warm  water  and  thereupon  inserted  into  the  stomach 
of  the  jDatient.  It  is  best  to  begin  with  the  spray  as 
soon  as  the  nozzle  (being  in  the  stomach)  is  at  a  dis- 
tance of  about  -±5  cm.  from  the  Hps  of  the  patient. 
Provided  the  nozzle  is  not  covered  by  the  stomach 
wall,  there  can  be  heard  during  the  spraying,  at  times 
in  the  neighborhood  of  the  patient — otherwise  by  put- 
ting the  ear  on  the  gastric  region — the  sound  charac- 
teristic of  the  spray.  In  case  the  opening  is  covered, 
the  spray  is  generally  unable  to  pass,  and  it  is  then 
necessary  to  insert  the  tube  a  little  farther. 

Even  if  the  spray  works  well  from  the  beginning,  it 
will  be  expedient  after  a  while  to  introduce  the  tube  a 
little  farther,  in  order  to  have  the  spray  work  from 
different  points.  The  spraying  of  the  stomach  has 
proved  very  useful,  according  to  m}^  experience,  in  the 
following  conditions:  (1)  In  erosions  of  the  stomach; 
(2)  in  those  forms  of  chronic  gastric  catarrh  which 
are  associated  with  an  abundant  amount  of  mucus; 
{^))  in  cases  of  hypersecretion  and  hyperacidity. 

4.  Electricity. 

In  view  of  the  firm  foothold  gained  by  electricity  in 
the  therapeusis  of  gastric  and  intestinal  disorders,  it 
will  not  appear  superfluous  to  give  a  brief  review  of 
the  history  and  physiological  action  of  this  agent  with 
reference  to  the  digestive  tract. 

Numerous  experiments  have  been  made  in  the  study 
of  the  influence  of  electricity  upon  the  stomach  and 
intestines ;  all  of  them  serve  to  demonstrate  the  physi- 
ological effects  of  this  agent. 


LOCAL   TREATMENT    OF   THE    STOMACH.  137 

Ludwig  and  Weber,'  von  Ziemssen/  and  Bocci' 
have  stated  that  in  animals  the  faradic,  as  well  as  the 
galvanic,  current,  applied  directly  to  the  stomach, 
causes  contractions  of  this  organ,  and  produces  secre- 
tion of  gastric  juice. 

Schillbach,"  u^jon  applying  the  galvanic  current  to 
the  bowels  of  a  rabbit,  observed  intense  contractions 
at  the  site  of  the  anode,  followed  by  peristaltic  move- 
ments. Fubini  ^  lately  demonstrated,  after  making  a 
Vella's  double  intestinal  fistula,  that  electricity  quick- 
ens intestinal  peristalsis  to  a  high  degree,  viz.,  about 
five  or  six  times. 

The  influence  of  electricity  upon  the  stomach  and 
intestines  thus  being  evident,  many  authors  en- 
deavored to  make  use  of  this  means  in  the  thera- 
peutics of  these  organs. 

For  many  years  past  numerous  writers  have  em- 
ployed electricity  in  affections  of  the  stomach  and  in- 
testines. The  method  generally  used  for  this  purpose 
consisted  in  the  percutaneous  application  of  the  cur- 
rent ;  usually  one  electrode  was  held  in  the  neighbor- 
hood of  the  vertebral  column  at  about  the  sixth  dorsal 
vertebra  on  the  left  side,  the  second  electrode  being 
placed  at  the  epigastrium. 

A.  D.  Eockwell  and  M.  Beard  *  were  among  the  first 

•  Ludwig aufl  Weber:  Cited  from  Kussmaul,  Arch.  f.  Psych,  und 
Nerv.,  1877,  Bd.  viii.,  p.  205. 

^Von  Ziemssen  :  Klin.  Vortrage,  No.  13,  "Die  Electricitat  in 
der  Medicin." 

^  Bocci :  Lo  Sperimentale,  June,  1881. 

^Schillbach:  Virch.  Arch.,  Bd.  109,  p.  284. 

5 Fubini:  Centralbl.  f.  d.  med.  Wissensch.,  1882,  No.  33,  p.  579. 

8  A.  D.  Rockwell  and  M.  Beard  :  Philad.  Med.  Surg.  Eeport. , 
1868,  No.  20,  and  1871,  p.  470. 


138  DISEASES   OF   THE   STOMACH. 

to  make  use  of  electricity  on  a  large  scale  in  the  treat- 
ment of  nervous  dyspepsias.  To  the  application  of 
electricity  to  the  stomach  they  added  general  electri- 
zation, and  had  the  most  brilliant  results. 

Xeftel '  likewise  had  much  success  from  the  electri- 
cal treatment. 

Fuerstuer "  recommends  the  galvanic  current  for  the 
treatment  of  atonic  dilatations  of  the  stomach. 

Oka  and  Harada/  Leu  be,  *  JLicnte,  ^  Semmola,' 
Ritcher'  and  Leubuscher,^  speak  highly  of  the  applica- 
tion of  the  electric  current  in  various  pathological 
conditions  of  the  stomach  and  intestines. 

Besides  these  clinical  facts,  there  have  lately  been 
added  some  more  exact  notes  as  regards  the  physiolog- 
ical effects  of  percutaneous  electricity  of  the  stomach 
in  man.  Ewald  and  myself  have  been  able  to  demon- 
strate an  acceleration  of  the  motor  faculty  of  the 
stomach  under  the  influence  of  percutaneous  faradiza- 
tion, by  the  appearance  of  the  salol  test  in  the  urine 
about  one-fourth  of  an  hour  earlier  than  otherwise.  A. 
Hoffmann  "showed  that  the  galvanic  current  percuta- 
neously  applied  in  the  gastric  region  for  twenty  minutes 
produces  an  abundant  secretion  of  gastric  juice. 

'Xeftel:  Centralbl.  f.  d.  rued.  Wissensch.,  1876,  No.  21,  p.  370. 

*  Fuerstner :  Berl.  klin.  "Wocliensch.,  1876,  No.  11. 

'Oka  and  Harada :  Berl.  klin.  Wochenscl).,  1876,  No.  44. 

^Leube:  Deutsch.  Arch.  f.  klin.  Medicin,  1879,  tome  23,  p.  98. 

»Lente:  Arcli.  of  Electrol.  and  Neurol.,  1874,  i.,  p.  193. 

*Semniola:  "L'elettricita  nel  vomito. "  Gaz.  nied.  Ital.  Lorn- 
bard..  1878,  No.  6. 

'Eichter:  Berl.  klin.  Wochensch.,  1882,  Nos.  13  and  14. 

8  Leubusclier :  Centralbl.  f.  klin.  Med.,  1887,  No.  25. 

'  Ewald  and  Einborn  :  Verbandhmgeu  des  Yereins  fiir  innere 
Medicin.  1888,  p.  58. 

J»A.  Hoffmann:  Berl.  klin.  Wocliensch.,  1889,  Nos.  13  and  13. 


LOCAL   TREATMENT   OF   TflE   STOMACH.  139 

Direct  Electrization  of  the  Stomach. 

Although  the  favorable  influence  of  electricity,  even 
percutaneously  applied,  is  quite  evident  in  numerous 
affections  of  the  stomach  and  intestines,  it,  however, 
remains  questionable  whether  any  of  the  produced 
electricity  penetrates  to  the  stomach.  The  main  cur- 
rents undoubtedly  go  through  the  skin  and  muscles, 
and  if  any  of  them  reach  the  stomach,  they  must  be 
very  weak.  But  surely  we  might  expect  to  attain 
better  and  more  successful  results  by  the  application 
of  electricity  directly  to  the  stomach.  In  his  cele- 
brated book  on  "Electrotherapy"  Erb'  says:  "The 
first  maxim  to  observe  is  the  treatment  in  loco  morhi, 
i.e.,  the  application  of  electricity  to  the  morbid  part 
itself.  .  .  .  There  is  no  doubt  that  it  is  best,  in  the 
great  majorit}^  of  cases,  to  operate  directly  on  the 
diseased  spot." 

Pepper'  had  a  patient  with  dilatation  of  the  stom- 
ach, in  whom  the  abdominal  walls  were  so  thin  that 
the  spontaneous  peristalsis  of  the  stomach  could  be 
perceived.  On  this  patient  he  showed  that  electricity, 
percutaneously  applied,  never  produced  any  peristaltic 
movements  of  the  stomach.  Pepper  then  continues  as 
follows:  "The  difficulty  of  compelling  a  current,  no 
matter  what  may  be  its  strength,  to  penetrate  through 
various  layers  of  tissue  of  different  consistence  and 
anatomical  character  is  well  known."  Speaking  of 
the  percutaneous  electricity  of  the  stomach,  Kussmaul ' 

•  Erb  :  "  Handbuch  der  Electrotherapie, "  p.  279. 

2  Pepper  :  Philadelphia  Medical  Times,  May,  1871,  p.  274. 

^Kussmaul;  Arch.  f.  Psych,  und  Nerv.,  1877,  viii.,  p.  205. 


1-iO  DISEASES    OF    THE    STOMACH. 

remarks :  "  The  therapeutic  results  obtained  by  Fuerst- 
ner  and  others  in  cases  with  dilatations  of  the  stomach 
do  not  prove  that  by  means  of  the  current  a  direct 
peristalsis  of  the  stomach  was  induced,  but  could  be 
attributed  to  the  favorable  influence  of  the  contrac- 
tions of  the  abdominal  walls."  All  the  sentences 
mentioned  plead  for  applying  electricity  to  the  stomach 
directly,  and  not  percutaneously,  if  possible. 

Canstatt  *  first  proposed  to  combat  dilatations  of  the 
stomach  by  direct  electrization,  introducing  one  elec- 
trode into  the  oesophagus  and  putting  the  other  in  the 
stomach  region.  Duchenne"  was  the  first  who  made 
use  of  this  method. 

Kiissmaurs  Method. — Very  soon  afterward,  in  1877, 
Kussmaul'  began  to  practise  the  direct  electrization 
of  this  stomach.  The  electrode  used  for  the  purpose 
consisted  of  a  stomach  tube,  through  which  ran  a  cop- 
per wire  ending  in  an  olive  point  and  fastened  to  the 
cut-off  end  of  the  tube.  In  several  patients  with  dila- 
tation of  the  stomach  Kussmaul  introduced  this  elec- 
trode into  the  stomach,  the  other  (ordinary)  electrode 
being  held  in  the  hand.  In  applying  electricity  in 
this  way  contractions  of  the  abdominal  muscles  on  the 
left  side  appeared,  and  in  one  patient,  with  thin  ab- 
dominal walls,  contractions  of  the  stomach  were  visible 
on  applying  weaker  electric  currents. 

Later  on  Balduino  Bocci,'  in  1881,  experimenting  on 
animals,  was  persuaded  "  that  the  indirect  faradization 


'  Canstatt :  Cited  from  Kussmaul,  I.  c. 
^  Duchenne  :  Cited  from  Kussmaul,  I.  c. 
^  Kussmaul :  L.  c. 
*  Bocci  -.  Lo  Sperimentale,  June,  1881. 


LOCAL    TREATMENT    OF    THE    STOMACH.  141 

of  the  stomach  through  the  abdominal  walls  produces 
in  the  stomach,  even  when  applied  in  a  very  energetic 
way,  phenomena  of  very  little  importance,  and  of  a 
dubious  curative  effect."  As  the  direct  faradization 
of  the  stomach,  on  the  other  hand,  showed  all  the 
above-mentioned  physiological  effects,  Bocci  recom- 
mended anew  the  use  of  the  direct  electrization  of  the 
stomach  for  therapeutic  purposes.  Bocci  used  for  this 
end  an  electrode  like  that  of  Kussmaul. 

BardeVs  MetJiod. — Great  progress  in  the  direct  elec- 
trization of  the  stomach  was  made  in  1884  by  G.  Bar- 
det.*  The  direct  contact  of  the  lower  metal  piece  of 
the  electrode  with  the  inner  wall  of  the  stomach  irri- 
tates only  a  small  spot,  and  this  very  intensely,  where- 
as the  larger  part  of  the  stomach  receives  but  very 
little  of  the  electricity  produced ;  in  consequence  thereof 
the  galvanic  current  could  not  be  applied,  because  by 
the  usual  method  it  would  not  be  possible  to  avoid  le- 
sions of  the  mucous  membrane  of  the  stomach.  In 
order  to  overcome  these  drawbacks  Bardet  constructed 
his  stomach  electrode  in  such  a  way  that  the  metal 
piece  running  through  the  tube  was  shorter  than  the 
tube,  and  did  not  touch  its  windows.  By  filling  the 
stomach  with  water  the  electric  circuit  between  the 
stomach  wall  and  the  lower  metal  piece  of  the  electrode 
was  established.  In  this  way  the  electricity  was  dis- 
tributed over  the  whole  surface  touched  by  the  water. 
By  means  of  this  electrode  Bardet  treated  three  cases 
of  dilatation  of  the  stomach,  and  one  case  of  obstinate 
vomiting,  with  the  galvanic  current  (15  to  25  milliam- 
peres)  and  obtained  splendid  results.  Most  authors 
'  Bardet :  Bull.  Gen.  de  Therap. ,  1884,  tome  106,  p.  539. 


142  DISEASES    OF    THE    STOMACH, 

who  employed  the  direct  electrization  of  the  stomach 
have,  until  recently,  generally  used  Bardet's  electrode. 
(Charles  G.  Stockton's*  stomach  electrode  does  not 
differ  very  much  from  that  of  Bardet.) 

Although  the  high  value  of  the  direct  electrization 
of  the  stomach  is  self-evident,  this  method  did  not 
enter  much  into  practice,  because  the  tube  surround- 
ing the  electrode  had  to  be  kept  in  the  throat  during 
the  whole  electric  session  (about  ten  minutes)  and  in- 
convenienced the  patient  to  such  a  degree  that  the 
procedure  could  be  carried  out  only  in  people  accus- 
tomed to  lavage  of  the  stomach,  and  even  by  them  it 
was  disagreeably  felt.  That  is  the  reason  why  von 
Ziemssen  ^  rejected  direct  electrization  of  the  stomach 
as  being  too  straining  and  exhausting. 

Einliorn^s  Method. 

In  order  to  facilitate  the  internal  or  direct  electriza- 
tion of  the  stomach  I  ^  have  constructed  an  electrode  on 
the  same  principle  as  the  stomach  bucket.  This  elec- 
trode once  swallowed  reaches  the  stomach  without 
further  artificial  aid.  The  silk  thread  of  the  bucket  is 
represented  in  the  electrode  by  a  very  fine  (1  mm.  in 
diameter)  rubber  tube  through  which  a  very  fine,  soft, 
conducting  wire  runs  to  the  battery.  The  end  piece 
of  the  electrode  consists  of  a  hard-rubber  capsule  with 
many  openings.     In  this  capsule  lies  a  metallic  button 

'  Charles  G.  Stockton  :  "A  New  Gastric  Electrode,  "Medical  Rec- 
ord, November  9th,  1889,  p.  530. 

*Von  Ziemssen:  "Ueber  die  physikalische  Behandlung  chro- 
nischer  Magen-  und  Darnikrankheiten, "  p.  10,  Leipzig,  1888. 

3  Max  Einhom  :  Medical  Record,  May  9th,  1891. 


LOCAL   TREATMENT    OF    THE    STOMACH. 


143 


which  is  connected  with  the  wire.      (Figure  37  shows 
the  electrode  in  natural  size.) 

The  rubber  capsule  serves  to  avoid  the  direct  contact 
of  the  metal  with  the  stomach  wall;  the  circuit  is 
completed  by  the  water  the  stomach  contains. 

This  electrode  I  have  termed  "  Deglutable  Stomach 
Electrode.'" 

Metliod. — ^The  patient  drinks,  best  when  in  a  fasting 
condition,  or  one  to 
two  hours  after  a 
light  breakfast,  one 
glassful  of  water,  tea, 
or  coffee.  The  patient 
has  now  to  open  his 
mouth  widely,  and 
the  electrode  (the 
capsule  piece)  is  placed 
far  behind  on  the  root 
of  the  tongue  and  he  is  ordered  to  swallow.  He  again 
drinks  some  water,  and  the  electrode  finds  its  way 
to  the  stomach  without  any  further  assistance. 

In  order  to  recognize  this  point  precisely,  it  is  ad- 
visable to  make  some  mark  on  the  tubing  at  a  distance 
of  40  cm.  from  the  capsule;  as  soon  as  this  mark  comes 
to  the  teeth  we  are  sure  that  the  electrode  is  in  the 
stomach  and  we  can  apply  the  electricity  to  the  pa- 
tient. 

According  to  my  belief,  it  is  of  importance  to 
apply  gastro-electrization  according  to  a  certain  plan. 
Thus  it  will  not  appear  superfluous  to  give  a  detailed 

'  The  Deglutable  Stoinach  Electrode  is  manufacttired  by  John 
Reynders  &  Co. ,  303  Fourth  Avenue,  New  York. 


Fig.  37 


-The  Deglutable  Stomach  Electrode 
(Einhorn). 


144  DISEASES    OF    THE    STOMACH. 

description  of  the  electric  application  I '  generally 
employ. 

The  patient,  when  the  deglutable  electrode  is  within 
the  stomach,  opens  his  clothes,  so  that  the  abdomen  is 
accessible.  The  key  of  the  deglutable  electrode  is  con- 
nected with  the  cord  (negative  pole)  running  to  the 
battery. 

Gastrofaradization. — Sitting,  ten  minutes;  at  first 
large  plate  electrode  at  the  gastric  and  epigastric  re- 
gion for  five  minutes,  then  a  small  ordinary  sponge 
electrode.  The  electrode  is  at  first  moved  up  and 
down  from  left  to  right  in  the  gastric  region  (some- 
times, especially  when  there  is  constipation,  the  elec- 
trode is  passed  over  the  region  of  the  colon — ascendens, 
transversum,  descendens — always  beginning  in  the 
right  iliac  region  and  stoj^ping  at  the  left  iliac  region 
[duration,  two  minutes]);  thereafter  one  proceeds 
from  the  gastric  region  from  right  to  left  to  the  back, 
and  remains  at  the  left  side  of  the  seventh  dorsal 
vertebra  for  one  minute.  (At  this  place  the  current 
can  be  ai^plied  quite  strongly,  and  most  of  the  patients 
then  experience  a  slight  sensation  within  the  stomach; 
the  patients  find  it  difficult  to  describe  this  sensation ; 
some  assert  that  they  experience  a  Iragging  feeling, 
others  a  feeling  of  weight,  and  others  again  of  pinch- 
ing. All  of  them  refer  this  feeling  to  the  stomach  and 
locate  it  opposite  different  heights  of  the  abdominal 
wall.)  We  then  return  to  the  front,  moving  the 
electrode  gently  up  and  down  over  the  gastric  region 

'Max  Einhorn :  "Therapeutic  Eesults  of  Direct  Electrization  of 
the  Stomach,"  Medical  Record,  January  30th  and  February  6th, 
1893. — "Furtlier  Experiences  with  Direct  Electrization  of  the  Stom- 
ach," New  York  Medical  Journal.  July  8th,  1893. 


LOCAL  TREATMENT   OF   THE   STOMACH.  145 

for  two  minutes,  gradually  decreasing  the  current,  and  . 
thus  ends  the  sitting.     The  current  has  to  be  of  such 
a  strength  that  it  causes  distinct  contractions  of  the 
abdominal  walls ;  but  it  is  not  well  to  have  it  so  strong 
that  the  patient  experiences  pains. 

Gastrogalvanization. — Negative  pole  within  the 
stomach ;  small  sponge  electrode.  Duration,  eight 
minutes.  First,  two  minutes  below  the  ensiform  proc- 
ess (during  the  first  minute  the  current  is  gradually 
increased  to  its  necessary  strength),  then  for  three 
minutes  moving  the  electrode  up  and  down  the  gastric 
region.  After  this,  we  then  go  to  the  back  and  re- 
main one  minute  at  the  left  side  of  the  seventh  dorsal 
vertebra,  return  to  the  front,  move  the  electrode 
around  the  gastric  region  for  one  minute,  and  remain 
then  quietly  for  one  minute  below  the  ensiform 
process.  During  this  time  the  current  is  gradually 
weakened  and  the  sitting  is  ended ;  the  strength  of 
the  current  is  ordinarily  fifteen  to  twenty  milliamperes. 

In  withdrawing  the  electrode  a  resistance  is  felt  at 
the  introitus  oesophagi;  it  is  not  advisable  to  pull  the 
electrode  with  force.  One  has  only  to  make  the 
patient  swallow  once  or  twice,  and  to  make  use  of  the 
moment  when  the  larynx,  by  this  act,  ascends  and 
the  passage  becomes  free,  to  withdraw  the  electrode, 
which  is  done  now  with  perfect  ease.  I  ordinarily 
apply  the  electrization  every  other  day  during  the  be- 
ginning of  treatment;  afterward — i.e.,  after  the  lapse 
of  two  to  three  weeks — twice  weekly  for  about  three 
weeks,  and  thereafter  once  a  week  for  some  time. 
As  a  rule,  I  begin  to  .decrease  the  frequency  of  the  sit- 
tings when  I  notice  a  decided  improvement  in  the 
u 


146  DISEASES   OF   THE   STOMACH. 

conditioD  of  the  patient.  Even  after  a  complete  dis- 
appearance of  the  symptoms  it  is  advisable  to  continue 
the  electrization  (once  a  week)  for  some  time. 

Direct  electrization  of  the  stomach  by  means  of  the 
degliitable  electrode  is  very  simple  and  handy  for  the 
patient  and  for  the  physician,  and,  as  it  seems  to  me. 
as  easy  to  apply  as  percutaneous  electrization.  After 
the  first  application  the  insertion  of  the  electrode  is 
much  easier,  the  patient  being  accustomed  to  the 
procedure. 

The  principal  advantage  of  the  deglutable  electrode 
consists,  firstly,  in  that  we  are  able  to  apply  the 
method  in  persons  not  used  to  the  stomach  tube,  and, 
secondly,  in  that  the  thin  cord  does  not  cause  any  un- 
comfortable feeling  to  the  patient  during  the  entire 
electric  sitting  and  does  not  provoke  salivation. 
Another  advantage  lies  in  the  circumstance  that 
the  deglutable  electrode  can  be  swallowed  even  in 
those  cases  in  which  ulcer  of  the  stomach  is  sus- 
pected, whereas  the  old  stomach  electrode  could  not 
be  introduced  in  them  for  fear  of  causing  perforation. 

By  means  of  the  deglutable  electrode  a  regular 
course  of  electric  treatment  of  the  stomach  becomes 
possible  in  many  cases  and  is  facilitated  in  all. 

I  have  made  an  extensive  study  of  the  physiological 
effects  of  direct  electrization  of  the  stomach  and  have 
published  the  results  in  several  papers.  From  my 
experiments  it  follows  conclusively  : 

1.  Direct  faradization  of  the  stomach  increases  gas- 
tric secretion  (a)  during  the  application  of  electricity 
and  also,  (6)  for  a  short  period  afterward. 

2.  Direct   galvanization    of  the   stomach   with  the 


LOCAL  TREATMENl-  OB    THE   STOMACH.  147 

negative  pole  within  the  organ  in  most  instances 
diminishes  gastric  secretion. 

3.  Direct  faradization  as  well  as  galvanization  of 
the  stomach  increases  the  absorbent  faculty  of  the 
stomach. 

As  regards  therapeusis  I  came  to  the  following 
conclusions : 

1.  Direct  gastro-electrization  is  a  potent  agent  in 
the  field  of  chronic  (non-malignant)  diseases  of  the 
stomach. 

2.  Direct  gastrofaradization  proves  to  be  useful  in 
many  ways  in  most  chronic  diseases  of  the  stomach. 
The  favorable  results  appear  very  clearly  and  pretty 
quickly  in  those  cases  of  stomach  dilatation  which  are 
not  caused  by  any  obstruction  of  the  pylorus,  but 
merely  by  the  relaxation  of  the  muscular  coat  of  the 
stomach.  Here  the  gastrofaradization  is  beneficial, 
no  matter  whether  in  these  cases  there  is  hyperacidity 
or  subacidity  of  the  stomach  contents.  Cases  of  relax- 
ation of  the  cardia  (eructations),  and  also  of  relaxation 
of  the  pylorus  (presence  of  bile  secretion  in  the  stom- 
ach), were  very  favorably  influenced  by  faradization. 
Here  the  result  was  most  markedly  pronounced, 
inasmuch  as,  besides  the  subjective  amelioration 
of  the  patient,  the  objective  examination  showed  at 
the  same  time  the  absence  of  bile  in  the  stomach  con- 
tents. 

3.  Gastrogalvanization  is  almost  a  sovereign  means 
for  combating  severe  and  most  obstinate  gastral- 
gias,  no  matter  whether  their  origin  is  of  a  ner- 
vous nature  or  caused  by  a  cicatrized  ulcer  of  the 
stomach. 


148  DISEASES  OP  THE   STOMACH. 

4.  Gastrogalvanization  exerts  also  a  favorable  in- 
fluence on  several  affections  of  the  heart  complicated 
with  gastralgia. 

With  regard  to  the  effects  of  the  current  in  diseases 
of  the  stomach,  it  is  very  difficult  to  give  a  full  theo- 
retical explanation,  I  perfectly  agree  with  Stockton/ 
who  says : 

"  Exactly  what  role  is  played  by  faradization  I  am 
unable  to  state;  whether  it  is  a  gastric  sedative  or  a 
gastric  stimulant  I  do  not  know.  My  efforts  were  in 
the  direction  of  study,  and  the  results  were  so  favor- 
able that  I  applied  faradism  to  cases  seemingly  contra- 
dictory in  character,  and  I  have  concluded  that  the 
great  variety  of  gastric  neuroses  depend  upon  a  com- 
mon cause — an  imperfect  innervation  of  the  stomach ; 
that  electricity  improves  this  innervation,  thereby  re- 
lieving the  cause  and  so  the  conditions  w^hich,  at  first 
thought,  are  so  contradictory," 

In  therapeusis  the  chief  factor  in  determining  the 
efficacy  of  any  means  of  treatment  is  and  will  be  our 
empirical  experience.  For  this  reason  I  do  not  think 
it  necessary  to  go  into  further  details  of  the  manner 
in  W'hich  electric  currents  act  upon  the  human  organ- 
ism. The  very  numerous  successful  results  obtained 
by  this  method  of  treatment  warrant  its  general  use 
in  practice. 

Since  the  publication  of  my  papers  on  direct  electri- 
zation of  the  stomach  many  authors  in  this  country  as 
well  as  in  France  and  Germany  have  made  use  of  this 
method  of  treatment  and  highly  recommend  it.     Thus 

'  Charles G.  Stockton  :  "Clinical Results  of  Gastric  Faradization. " 
American  Journal  of  the  Medical  Sciences,  1890,  p.  20. 


LOCAL  TREATMENT   OF   THE    STOMACH.  149 

Stockton,  Ewaldj  Eave,' A.  A.  Jones,"  D.  D.  Stewart,' 
Eosenheim,*  Brock,"  Goldschmidt,"  and  others  have 
pubhshed  good  results  obtained  by  intragastric  electri- 
zation. Ewald  approves  of  the  shape  and  form  of  my 
electrode,  but  finds  it  difScult  to  introduce  it  into  the 
patient's  stomach.  For  this  reason  he  has  modified 
my  electrode  by  using  a  thicker  rubber  tubing  around 
the  wire :  the  tubing  corresponds  to  No.  1 3  Charriere 
and  is  about  1^  mm.  thick.  I  have  not  found,  how- 
ever, that  the  insertion  into  the  stomach  of  the  de- 
glutable  electrode  offers  any  difficulties. 

The  principal  point  is  to  put  the  electrode  far  back 
into  the  pharynx  and  to  let  the  patient  meanwhile 
drink  something.  It  is  advisable  to  have  the  patient 
drink  slowly  about  a  glassful  of  water,  and  to  have  a 
talk  with  him,  in  order  to  distract  his  attention  from 
the  procedure.  The  electrode  usually  soon  reaches  the 
stomach,  and  it  seldom  happens  that  it  remains  lying 
in  the  fauces.  If  this  does  happen,  the  patient  must 
eat  a  small  piece  of  bread  and  drink  some  water;  the 
electrode  will  then  find  its  way  into  the  stomach  with 
the  bread. 

If  in  a  very  rare  case  the  deglutable  electrode  can- 
not be  introduced,  there  is  yet  always  time  to  use  in- 
stead the  electrode  as  modified  by  Ewald. 

'J.  Rave:  "Contribution  a  1' etude  du  traitement  des  dyspepsies 
par  I'electricite, "  Paris,  1893. 

2  Allen  A.  Jones:  Medical  Record,  June  13th,  1891. 

3  D.  D.  Stewart :  Therap.  Gazette,  1893,  p.  744. 
4 Rosenheim:  Berliner  Klinik.,  May,  1894. 

5 Brock:  Therap.  Mouatshefte,  1895,  p.  275. 

^  Goldschmidt :  "Ueber  den  Einfluss  der  Elektricitat  auf  den 
gesunden  und  kranken  menschlichen  Magen."  Deutsch.  Arch.  f. 
klin.  Med.,  vol.  xv.,  p.  295. 


160  DISEASES   OF   THE   STOMACH, 

Wegele '  has  lately  devised  a  new  gastric  electrode 
which  he  terms  the  sj)iral  electrode.  Inasmuch  as 
this  electrode  has  to  be  used  through  a  stomach  tube, 
it  has  no  advantage  whatever  over  the  ordinary  stom- 
ach electrodes  formerly  in  use,  as  the  principal  prog- 
ress achieved  by  means  of  the  deglutable  electrode 
is  that  the  stomach  tube  can  be  dispensed  with  in  the 
application  of  electricity.'' 

>  Wegele ;  Therap.  Monatshefte,  1895,  p.  195. 

2  Internal  massage  of  the  stomach  has  been  recently  suggested  by 
Dr.  Fen  ton  B.  Turck,  of  Chicago,  111.,  by  means  of  his  "gyromele" 
or  "revolving  sound."  This  instrument  consists  of  a  flexible  cable, 
to  the  end  of  which  is  attached  a  sponge  covering  a  spiral  spring, 
which  can  be  removed  from  the  cable  at  will  and  changed.  The 
cable  passes  through  a  rubber  tube,  and  this  again  is  attached  to  a 
revolving  apparatus,  for  the  purpose  of  producing  revolutions  of  the 
sponge.      (See  American  Medico-Surgical  Bulletin,  July  1st,  1895.) 


CHAPTER  Y. 

ORGANIC  DISEASES   WITH   CONSTANT 

LESIONS. 

The  Acute  Ajst)  Chronic  Gastric  Catarrh. 

1.    Acute  Gastritis. 

Synonyms. — Gastritis  glandularis  acuta;  acute  gas- 
tric catarrh ;  catarrhus  ventriculi  acutus. 

Definition. — An  inflammation  of  the  gastric  mucous 
membrane,  resulting  in  disturbances  of  digestion. 

Acute  gastritis  may  be  divided  into  the  three  follow- 
ing forms :  Gastritis  acuta  simplex,  gastritis-phlegmo- 
nosa,  and  gastritis  toxica. 

Gastritis  Acuta  Simplex  or  Acute  Gastric  Catarrh. 

Etiology. — Acute  gastric  catarrh  is  one  of  the  dis- 
eases most  frequently  met  with  in  the  practice  of  the 
physician,  and  occurs  at  all  ages  and  among  all  classes 
of  society.  It  is  usually  attributable  to  errors  in  diet, 
the  chief  cause  being  an  abnormal  quantity  of  ingesta.  ; 
Irritation  followed  by  inflammation  of  the  stomach 
often  results  from  the  use  of  very  hot,  but  especially 
ice-cold  drinks,  or  from  too  highly  spiced  or  fermented 
foods.  If  food  be  imperfectly  masticated  and  swal- 
lowed in  big  lumps,  it  may  mechanically  disturb  the 
stomach  and  lead  to  inflammation.     The  same  effect 


15-2  DISEASES    OF    THE    STOMACH. 

is  induced  by  maDv  irritatiDg  substances,  as,  for  in- 
stance, alcohol,  rancid  butter,  etc. 

The  sensibility  of  the  stomach  is  not  always  alike. 
One  of  the  above-named  causes  may  be  productive  of  a 
catarrhal  condition  in  one  person,  while  in  many  others 
it  remains  perfectly  inactive.  The  tendency  to  acute 
catarrh  of  the  stomach  varies  very  much  in  different 
individuals  and  families.  Some  people  have  a  certain 
predisposition  for  this  affection,  which  is  designated 
by  the  expression  "'delicate  stomach."  The  latter  is 
often  found  in  anaemic  women,  in  old  persons,  and  in- 
valids of  all  kinds.  The  question  whether  the  acute 
gastric  catarrh  may  originate  by  way  of  infection  has 
not  as  yet  been  settled.  The  epidemic  appearance  of 
this  affection  at  a  certain  time  speaks  in  favor  of  such 
an  assumption,  which  was  first  propagated  by  Lebert  * 
and  Oser.^  Xo  micro-organisms,  however,  have  been 
found  within  the  stomach  wall  to  corroborate  this 
theory.  Besides  the  above-named  direct  causes,  acute 
gastric  catarrh  is  indirectly  engendered  by  all  acute 
infectious  diseases,  which  it  ordinarily  accompanies. 

Morbid  Anatomy. — As  gastritis  as  such  hardly  ever 
causes  death,  and  inasmuch  as  the  stomach  after  death 
quickly  undergoes  radical  changes  which  destroy  the 
true  picture  that  had  before  existed,  the  minute  his- 
tology of  the  affected  stomach  can  be  studied  only 
with  the  greatest  difficulty.  Even  nowada3's  we  have 
no  better  description  of  the  macroscopical  aspect  of  the 
inflamed  organ  than  that  given  nearly  seventy  years 

'  Lfibert :  "Die  Krankheiten  des  Magens."  Tubingen,  1878,  p.  29. 
^Oser:     -'Magenkrankheiteu."      Eulenburg's     "  Realencjclopje- 
dia, "  vol.  xii. ,  p.  410. 


GASTEITIS    ACUTA   SIMPLEX.  153 

ago  by  Beaumont '  from  his  observations  made  on  the 
well-known  Canadian  St.  Martin  with  his  gastric  fis- 
tula. The  mucous  membrane  appears  entirely  or  par- 
tially swollen  and  reddened  and  is  marked  here  and 
there  with  small  sacculations.  Less  gastric  juice  is 
secreted,  and  mucus  covers  the  surface.  The  pyloric 
portion,  as  a  rule,  is  more  affected,  and  there  exist  more 
or  less  extensive  extravasations  of  blood.  The  secre- 
tion is  only  weakly  acid  or  neutral,  or  even  alkaline. 

Microscopically  the  principal  cells  are  found  to  be 
more  granular  and  cloudy,  partly  fatty  and  shrunken. 
There  is  no  distinction  possible  between  the  parietal 
and  the  principal  cells.  In  the  interglandular  tissue 
numerous  round  cells  are  found.  They  are  also  met 
with  between  the  epithelial  cells  and  appear  to  be 
wandering  to  the  surface.  These  round  cells,  accord- 
ing to  Sachs, ''  give  distinct  pictures  of  karyokinesis. 

Symptomatology. — 'Immediately  after  a  manifest 
indiscretion  of  diet  there  is  experienced,  first  of  all,  a 
feeling  of  heaviness  at  the  pit  of  the  stomach;  later 
on  a  sensation  of  fulness.  There  is  a  desire  to  belch, 
and  a  difficulty  in  doing  so.  After  belching,  the  pa- 
tient feels  easier  for  a  little  v/hile,  but  soon  the  heavy 
sensation  reappears.  This  condition  may  persist  un- 
changed for  a  few  days,  and  then  gradually  disappear. 
This  is  the  mild  form  of  the  acute  catarrh.  Very 
often,  however,  w^e  meet  with  more  alarming  symp- 
toms. At  the  beginning  there  may  exist  nausea,  a 
sensation   of   weight,    and   slight   pains   in   the   gas- 

'  Beaumont :  I.  c. 

2  A.  Sachs  :  "  Zur  Kenntniss  der  Magenschleimhaut  in  krankhaf  ten 
Ziistanden."  Arch.  f.  experim.  Pathologie,  Bd.  23,  Heft  3,  and  Bd. 
34,  Heft  1  and  3. 


154  DISEASES   OF  THE   STOMACH. 

trie  region,  severe  headache,  sometimes  rise  of  tem- 
perature, later  on  vomiting,  extreme  anorexia,  con- 
stipation, or  diarrhoea.  Soon  the  symptoms  become 
less  severe,  and  appear  as  described  in  the  milder  form. 

Objectively  the  gastric  region  appears  bloated,  and 
is  sensitive  to  pressure.  The  tongue  is  thickly  furred, 
and  the  taste  pappy.  If  vomiting  occurs,  the  ejected 
matter  contains  no  free  hydrochloric  acid,  is  of  a 
slightly  acid  or  neutral  or  alkaline  reaction,  and  is 
frequently  mixed  with  a  great  deal  of  mucus. 

The  duration  of  the  affection  is  short,  as  a  rule  from 
one  to  three  days.  The  more  severe  cases  begin  with 
a  sudden  rise  of  temperature  (102°  to  lOi"  F.),  which 
may  be  accompanied  with  chills.  In  such  instances 
the  gastric  symptoms  may  at  first  be  less  marked  than 
the  symptoms  caused  by  the  fever.  After  a  short 
period,  however,  the  gastric  symptoms  become  more 
pronounced. 

The  inflammatory  process  of  the  stomach  not  rarely 
extends  into  the  intestines,  and  then  causes  constipa- 
tion or  diarrhoea.  The  affection  may  also  invade  the 
gall  bladder,  and  then  gives  rise  to  icterus.  In  the 
febrile  form  of  gastritis  herpes  labialis  is  of  frequent 
occurrence. 

Diagnosis. — It  is  easy  to  make  the  diagnosis  in 
those  cases  which  are  not  accompanied  by  fever,  and 
where  the  cause  of  the  trouble  is  apparent.  The 
analysis  of  the  gastric  contents  or  of  the  vomited 
matter  shows  a  marked  diminution  in  the  secretion  of 
gastric  juice.  An  acute  gastritis  accompanied  by 
fever  will  at  times  cause  some  difficulty  in  diagnosis. 
As  is  well  known,  most  of  the  infectious  diseases  are 


GASTRITIS   ACUTA   SIMPLEX.  155 

accompanied  by  gastric  catarrh  at  their  commence^ 
ment,  but  they  can  be  easily  excluded  by  the  absence 
of  their  pathognomonic  symptoms.  It  is  less  easy  to 
make  a  differential  diagnosis  between  a  beginning 
typhoid  fever  and  acute  gastric  catarrh.  In  fact,  the 
distinction  between  these  two  conditions  is  sometimes 
almost  impossible  during  the  first  and  second  days  of 
the  sickness. 

The  following  may  serve  as  differential  points  of 
diagnosis  between  these  two  conditions : 

In  typhoid  fever  the  temperature  is  characterized  by 
its  gradual  rise,  while  in  gastric  catarrh  the  rise  of 
temperature  is  quite  sudden  ;  we  may  have  at  the  very 
start  a  temperature  of  103°  or  104°.  The  remission  in 
gastric  catarrh  will  likewise  be  more  pronounced. 
The  presence  of  herpes  labialis  will  speak  in  favor  of 
gastric  catarrh,  while  the  appearance  of  Ehrlich's 
diazo  reaction  in  the  urine  will  point  to  typhoid  fever. 

Biliary  calculi  not  causing  very  severe  pains,  and 
not  accompanied  by  icterus,  may  sometimes  be  mis- 
taken for  a  gastric  catarrh.  Such  an  error  in  diagno- 
sis will,  however,  occur  but  seldom ;  as  a  rule,  it  is 
easy  to  differentiate  between  these  two  conditions. 

Prognosis. — ^The  prognosis  of  gastric  catarrh  is  very 
favorable,  except  in  cases  of  very  old  people  and  in- 
valids, in  which  the  process  may  cause  serious' compli- 
cations. 

Treatment. — The  vis  medicatrix  naturce  is  best  seen 
in  this  affection.  In  order  to  become  freed  of  the  un- 
digested material,  the  stomach  empties  itself  either  by 
vomiting  or  transferring  its  contents  into  the  small 
intestines,  which  in  turn  get  rid  of  them  by  diarrhoeal 


156  DISEASES    OF   THE    STOMACH. 

passages.  The  anorexia  prevents  the  patient  from 
taking  food,  and  in  this  way  the  stomach  can  enjoy 
perfect  rest  and  soon  recuperate. 

In  our  treatment  we  have  to  imitate  or  rather  assist 
nature.  If  spontaneous  vomiting  does  not  take  place, 
and  a  feeling  of  pressure  and  pains  in  the  stomach  are 
present,  if  percussion  over  the  gastric  region  gives  dul- 
ness,  and  belching  of  badly  smelling  gases  occurs, 
then  we  ma}'  be  certain  that  all  the  symptoms  men- 
tioned are  caused  by  decomposed  food  within  the 
organ.  Here  it  is  best  to  look  for  means  which  will 
remove  this  obnoxious  material.  Washing  out  of  the 
stomach  is  the  best  way  to  accoixiplish  this  end.  In- 
stead of  lavage,  however,  we  ma}'  tell  the  patient  to 
drink  half  a  pint  or  even  a  pint  of  lukewarm  water  in 
which  a  small  quantity  of  table  salt  has  been  dissolved, 
and  then  tickle  the  throat  with  the  end  of  a  quill  or 
with  the  finger  in  order  to  produce  vomiting.  Cam- 
omile tea  can  also  be  taken  in  the  same  manner  before 
bringing  on  vomiting. 

Emetics  are  rarely  given  nowadays.  In  suitable 
cases  it  is  best  to  make  use  of  the  subcutaneous  injec- 
tion of  apomorphine  (the  dose  being  about  one-half  a 
centigram).  Tartar  emetic  and  ipecacuanha  should 
never  be  employed  except  in  children.  The  stomach 
after  having  been  emptied  should  now  enjoy  perfect 
rest  for  some  time. ,  Thus  during  the  first  or  second 
day  of  illness  it  is  best  not  to  give  the  patient  any- 
thing substantial  to  eat.  Strained  barley  or  rice 
water  or  weak  tea  may  be  taken.  On  the  third  day, 
as  soon  as  the  appetite  reappears,  the  patient  is  per- 
mitted   to   partake   of   a  water  soup   (bread  and  hot 


GA.STRIT1S    ACUTA    SIMPLEX.  157 

water),  of  oatmeal  or  barley  gruel,  rice  soup,  and  per- 
haps oue  soft-boiled  egg.  Later  on  French  bread, 
butter,  and  oysters  may  be  added  to  the  dietary.  If 
the  improvement  is  steadily  progressing,  we  begin  on 
the  fourth  day  with  meat  once  a  day,  and  thus  slowly 
return  to  the  usual  bill  of  fare.  As  a  rule,  no  medi- 
cines whatever  are  needed.  If  obstinate  constipation 
exists,  however,  and  the  bowels  have  not  moved  dur- 
ing the  first  two  days  of  sickness,  some  aperient  may 
be  given.  A  large  dose  of  calomel  (ten  to  fifteen 
grains)  administered  once  is  very  serviceable.  This 
remedy  should  especially  be  employed  in  the  febrile 
form  of  gastritis.  If  there  is  no  fever,  Seidlitz  pow- 
ders or  a  good  dose  of  citrate  of  magnesia  will  serve 
the  purpose. 

In  rare  instances  in  which  the  symptoms  appear  in 
a  very  aggravated  form  they  may  require  special  at- 
tention. A  pronounced  sensation  of  jDressure  and  ful- 
ness in  the  gastric  region  after  the  ingestion  of  food 
may  be  relieved  by  small  doses  of  dilute  hydrochloric 
acid  (ten  drops  in  a  glassful  of  water  three  times  daily 
half  an  hour  after  meals). 

A  high  degree  of  pyrosis  can  be  relieved  by  the 
following  medication : 

I^  Calcined  magnesia, 

Sodium  bicarbonate, 

Peppermint  sugar, aalO.O 

M.  f .  pulv.     D.   ad  scatulam.     S.  A  point  of  a  knife  every  two 
hours. 

Severe  pains  may  be  relieved  by  a  small  dose  of 
codeine: 

I^  Codein.  phosph 0.1 

Aq.  menth.  pip^  .         .         .         .         .        .40.0 

S.  One  teaspoonful  twice  or  three  times  daily. 


158  DISEASES  OP  THE   STOMACH. 


Gastritis  Phlegynonosa. 

Synonyms. — Gastritis  phlegmonosa  piiriilenta  ; 
purulent  inflammation  of  the  stomach. 

This  affection  usually  runs  an  acute,  and  very  rare- 
ly subacute  course.  The  inflammatory  process  is  sit- 
uated in  the  submucous  and  muscular  layers  of  the 
stomach,  differing  in  this  respect  from  acute  gastritis, 
in  which  the  glandular  layer  is  affected.  Phlegmon- 
ous gastritis  is  a  very  rare  disease  and  occurs  more 
frequently  among  men  than  women.  Two  forms  of 
this  affection  are  met  with:  the  primary  or  idiopathic 
and  the  metastatic.  Although  the  exact  cause  of 
primary  purulent  gastritis  is  as  yet  unknown,  the 
symptoms  and  course  of  the  morbid  process  justify 
the  assumj)tion  that  it  is  due  to  some  micro-organism. 
The  metastatic  form  occurs  in  pysemic  and  puerperal 
fever  or  severe  exanthemata. 

Morbid  Anatomy. — There  may  be  present  either  a 
circumscribed  abscess  in  the  gastric  wall  (gastritis 
phlegmonosa  circumscripta  or  abscess  of  the  stomach), 
or  a  diffuse  purulent  infiltration.  In  the  latter  in- 
stance, numerous  small  abscesses  of  pea  or  hazelnut 
size  are  generally  found.  The  mucosa  over  these 
areas  apjDears  swollen.  The  abscesses  lie  in  the  sub- 
mucosa  or  muscularis  and  often  extend  to  the  serosa. 
If  the  purulent  process  progresses  further,  perforation 
may  occur  either  into  the  stomach  or  into  the  abdom- 
inal cavity. 

Symptomatology . — After  the  existence  of  dyspeptic 
symptoms  for  some  time,  or  without  any  previous  dis- 


GASTRITIS   TOXICA.  159 

turbanceSj  the  patient  suddenly  experiences  an  intense 
pain  in  his  gastric  region.  At  the  same  time  there 
appear  a  violent  burning  sensation  within  the  stom- 
ach, extreme  thirst,  dry  tongue,  and  perfect  anorexia. 
These  symptoms  are  accompanied  by  high  fever  (103'- 
105°  F.),  with  only  very  short  intermissions.  Some- 
times the  onset  of  the  disease  is  attended  by  chills. 
The  pulse  is  small  and  irregular.  In  most  instances 
there  is  vomiting  and  retching,  the  vomited  matter 
consisting  mainly  of  mucus  and  some  bile.  The  gas- 
tric region  is  very  painful  to  pressure.  The  bowels  are 
either  constipated,  or  (as  is  generally  the  case)  diar- 
rhoeal.  The  disease,  as  a  rule,  ends  fatally  in  a  very 
short  time  (four  to  seven  days).  It  may,  however, 
last  fourteen  days.  The  chronic  form  occurs  most 
frequently  in  the  course  of  the  so-called  gastric  ab- 
scess. 

Diagnosis. — An  exact  diagnosis  of  this  affection  can 
hardly  be  made  during  life.  If,  in  connection  with 
the  above  symptoms,  there  is  an  increased  resistance 
in  the  gastric  region  with  severe  pain  on  pressure,  we 
should  think  of  purulent  gastritis. 

Treatment. — ^The  treatment  should  be  symptomatic. 
Ice-cold  application  to  the  abdomen,  leeches,  large 
doses  of  opium,  or  subcutaneous  injections  of  mor- 
phine, and,  if  there  is  collapse,  camphor,  ether,  and  the 
like  will  have  to  be  administered. 

Gastritis  Toxica. 

Among  the  poisonous  substances  which  directly 
affect  the  gastric  mucous  membrane,  the  following  de- 
serve  special   notice:     Alcohol,   phosphorus,    arsenic, 


100  DISEASES   OF   THE   STOMACH. 

potassium  cyanide,  corrosive  sublimate,  nitrobenzol, 
potassium  chlorate,  concentrated  mineral  acids  (sul- 
phuric acid,  nitric  acid),  and  the  caustic  alkalies.  The 
first-named  substances  cause  an  intense  acute  gas- 
tritis. The  raucous  membrane  becomes  swollen  and 
superficially  necrotic,  leaving  behind  small  hemor- 
rhagic spots.  Microscopically  the  glandular  tubiili  are 
found  to  have  undergone  fatty  degeneration.  The 
latter  group  of  poisons  (acids  and  alkalies)  act  quite 
differently.  They  directly  destroy  the  parts  they  come 
in  contact  with  and  in  this  way  the  whole  mucous 
layer  may  become  destroyed ;  sometimes,  should  the 
poison  penetrate  still  farther,  the  submucosa  may 
also  be  destroyed,  and  rupture  of  the  stomach  takes 
place. 

Symptomatology. — The  symptoms  will  be  more  or 
less  marked  according  to  the  quantity  of  poison  taken. 
There  is  always  pain  in  the  gastric  region,  which  is  in- 
creased on  pressure.  Vomiting  is  of  very  frequent 
occurrence.  The  vomited  matter  may  contain  an  ad- 
mixture of  blood.  Thirst  is  always  present.  In  cases 
of  a  severe  nature  there  is  always  found  a  small  pulse, 
cyanosis,  cold  perspiration,  slight  coma,  and  death 
may  occur  in  collaj)se. 

In  other  cases  the  course  may  be  somewhat  more 
protracted  and  either  peritonitis  or  icterus,  hsematuria 
caused  by  the  poison  circulating  in  the  blood,  may  de- 
velop. In  those  instances  in  which  death  does  not  oc- 
cur there  may  arise — after  the  acute  symptoms  of 
poison  have  been  subdued — a  condition  which  is  simi- 
lar to  that  of  a  subacute  gastritis. 

It  sometimes,  though  seldom,  happens  that  the  mu- 


GASTRITIS   TOXICA.  161 

cous  membrane  of  the  stomach  is  affected  to  such  a 
high  degree  that  it  may  entirely  atrophy  and  then  a 
condition  of  achyha  gastrica  will  result.  In  cases  of 
poisoning  by  mineral  acids  or  caustic  alkalies,  it  may 
occur  that  in  consequence  of  the  sloughing  of  an  area 
situated  either  near  the  cardia  or  near  the  pylorus  a 
stricture  develops,  thus  causing  serious  complications. 
These  strictures  frequently  develop  later  on,  at  a 
time  w^hen  the  patient  perhaps  imagines  that  he  is 
entirely  rid  of  his  trouble.  The  stricture  of  the  cardia 
causes  dysphagia,  and  the  stricture  of  the  pylorus 
ischochymia. 

Diagnosis. — The  diagnosis  is  frequently  made  by 
the  cross-examination  of  the  patient,  provided  he  is 
able  to  state  w^hat  kind  of  poison  he  took.  The  in- 
spection of  the  mouth,  tongue,  and  pharynx  may  lead 
us  to  suspect  poisoning  by  mineral  acids  or  caustic 
alkalies,  as  both  cause  manifest  lesions  (sloughing)  at 
these  places  when  taken.  The  examination  of  the 
vomited  matter  will  also  frequently  lead  us  to  discover 
the  nature  of  the  poison. 

Prognosis. — The  prognosis  will  greatly  depend  upon 
the  quantity  of  poison  taken,  and  upon  the  condition 
in  which  we  find  the  patient.  On  the  whole,  every 
case  of  poisoning  must  be  considered  as  quite  serious, 
recovery  being  doubtful. 

Treatment. — In  all  cases  of  poisoning  by  concen- 
trated mineral  acids  and  caustic  alkalies,  the  best 
mode  of  treatment  is  to  effect  dilution  of  the  poison, 
and  if  possible  its  neutralization.  Thus  we  give  cal- 
cined   magnesia    (100    gm.    dissolved    in   a    pint    of 

milk)  to  the  patient  as  a  drink  in  case  the  poison  con- 
11 


162  DISEASES   OF   THE   STOMACH. 

sisted  of  a  mineral  acid;  the  magnesia  will  then  neu- 
tralize  the  acid.  On  the  other  hand,  we  administer  a 
drink  consisting  of  lemonade  or  a  weak  solution  of 
acetic  acid  (one  to  two  per  cent)  in  case  the  poi- 
sonous substance  had  been  a  caustic  alkali,  for  the 
reason  that  the  acid  introduced  forms  a  harmless  com- 
bination with  the  poison.  In  the  instances  just  men- 
tioned, lavage  cannot  be  used  for  fear  of  a  perforation 
of  the  stomach ;  nor  is  it  permitted  to  bring  on  vomit- 
ing, as  the  poisonous  matters  lodged  within  the  stom- 
ach would  cause  a  great  deal  of  harm  by  their  com- 
ing in  contact  with  the  oesophagus  and  mouth  when 
ejected. 

In  all  other  kinds  of  poisoning  (alkaloids  and  metals) 
it  is  always  best  to  use  lavage  as  early  as  possible,  in 
order  to  free  the  stomach  and  the  organism  of  that 
portion  of  the  poison  that  has  not  yet  entered  the  small 
intestines.  Although  an  emetic  (like  apomorphine)  can 
be  used  for  this  purpose,  siphonage  of  the  stomach  is, 
however,  by  all  means  preferable,  for  only  the  latter 
permits  a  thorough  emptying  and  cleaning  of  the  or- 
gan. It  is  not  the  place  here  to  speak  of  all  the  anti- 
dotes that  have  to  be  employed  in  these  cases.  The 
subsequent  treatment  will  always  depend  upon  the 
symptoms  in  each  given  case.  In  peritonitis  ice  will 
have  to  be  applied  on  the  abdomen,  and  opiates  freely 
given.  The  treatment  of  a  resulting  stricture  of  the 
cardia  or  of  the  pylorus  must,  in  most  instances,  be  a 
surgical  one.  In  the  former  cases,  dilating  of  the 
cardia  by  means  of  bougies  will  first  be  tried. 


CHRONIC   GASTRIC   CATARRH.  163 


2.  Chronic  Gastric  Catarrh — Gastritis  Glandularis 
Chronica. 

Definition. — Chronic  inflammation  of  the  gastric 
mucous  membrane,  causing  various  disturbances  in  the 
act  of  digestion. 

FatJwIogical  Anatomy. — The  mucosa  is  usually 
covered  with  a  thick  layer  of  tenacious  mucus  pre- 
senting a  yellowish-gray  or  slate-gray  color,  while 
some  parts  may  appear  intensely  red.  The  latter  con- 
dition is  frequently  found  in  the  secondary  catarrh 
caused  by  congestion.  The  mucosa  is  frequently 
thicker  than  normally,  and  forms  pajDillar^^  projec- 
tions, thereby  causing  the  so-called  etat  manielonne. 

As  a  rule,  the  pyloric  portion  of  the  stomach  is 
chiefly  involved.  The  inflammatory  process,  how- 
ever, may  sometimes  extend  over  the  entire  mucous 
membrane.  In  some  instances  the  submucosa  and 
muscularis  may  also  undergo  some  changes,  and  ap- 
pear either  in  a  hypertrophied  state  or  very  much 
atrophied.  Microscopically  the  glands  often  seem  en- 
larged, sacculated,  and  dilated  in  cyst-like  forms.  The 
tubuli  have  lost  their  normal  regular  arrangement  and 
show  an  atypical  distinct  ramification.  The  glandular 
cells  appear  granular  and  in  a  condition  of  fatty  de- 
generation, and  there  is  no  longer  any  difference  rec- 
ognizable between  the  principal  and  parietal  cells. 
An  abundant  small -celled  infiltration  is  present  which 
fills  the  interglandular  spaces  and  pushes  the  glands 
apart.  This  small-celled  infiltration  is  especially 
marked  near  the  surface  of  the  mucous  membrane. 


164  DISEASES   OF   THE   STOMACH. 

The  superficial  layer  of  the  epithelium  of  the  mucosa 
is  frequently  defective.  The  mouths  of  the  glands  are 
very  often  filled  with  a  pale  mucous  mass,  which  pro- 
jects against  the  lumen  without  any  enclosing  mem- 
brane. According  to  Ewald,'  there  is  a  condition  of 
mucous  catarrh  in  which  the  degeneration  may  be  ob- 
served to  extend  down  to  the  base  of  the  glands,  so 
that  in  place  of  the  ordinary  princijDal  and  parietal 
cells  we  find  cells  in  the  most  varied  stages  of  mucoid 
degeneration.  This  condition  is  especially  found  in 
the  pyloric  region.  Some  cells  may  be  found  which 
are  still  intact,  the  mucus  filling  only  a  small  part  of 
them,  while  the  rest  of  the  cell  is  occupied  by  granular 
protoplasm  and  a  large  nucleus.  In  others  the  mu- 
cus occupies  the  greater  part  of  the  cells  and  crowds 
the  protoplasm  and  the  flattened  nucleus  against  its 
base;  in  still  others  the  cell  membrane  has  ruptured, 
and  the  mucus  has  escaped  into  the  lumen  of  the  duct 
of  the  gland.  This  mucoid  degeneration  Ewald  found 
only  in  specimens  which  had  been  placed  while  still 
warm  in  alcohol.  In  older  specimens  the  condition 
above  described  could  not  be  discovered.  In  a  patient 
with  cancer  of  the  pylorus,  I  had  the  opportunity  to 
find  in  the  wash-water  a  small  piece  of  the  gastric 
mucosa.  It  was  placed  in  alcohol  at  once,  and  the 
microscope  revealed  a  beautiful  picture  of  mucoid 
degeneration  (see  Fig.  27). 

The  inflammatory  process  after  existing  for  a  long 
period  may  at  the  end  lead  to  a  total  destruction  of 
the  glandular  layer  of  the  entire  organ,  thereby  caus- 
ing a  condition  which  has  been  termed  atrophy  of  the 

'Ewald:  I.  c,  p.  318. 


CHRONIC   GASTRIC   CATARRH.  165 

stomach  or  anadenia  ventriculi  (Ewald).  Two  differ- 
eat  processes  ultimately  effect  this  condition. 

The  first  consists  in  a  fatty  degeneration  and  de- 
struction of  the  gland,  the  process  progressing  from 
the  surface  of  the  stomach  inwardly.  While  in  the 
early  stage  no  glands  are  found  on  the  surface  of  the 
mucosa,  there  still  exist  glandular  cysts  situated  near 
the  submucosa.  Later  on  even  these  glandular  cysts 
disappear,  and  the  whole  mucosa  consists  almost  en- 
tirely of  round,  cells.  According  to  Ewald,  this  proc- 
ess is  especially  met  with  in  those  instances  in  which 
the  entire  organ  is  more  or  less  dilated  and  the  walls 
thin.  The  submucosa  is  then  also  partly  changed,  the 
muscular  layer  being  much  thinner. 

The  second  process  takes  its  origin  in  the  submu- 
cosa, and  progresses  from  the  deeper  layers  to  the  sur- 
face of  the  stomach.  In  this  instance  the  fibrous  ele- 
ments play  the  greater  part.  The  inflammatory  proc- 
ess causes  the  formation  of  fibrous  tissue,  which 
spreads  around  the  glands  and  partly  constricts  them. 
The  glands  are  also  ultimately  destroyed  and  their 
place  taken  up  by  fibrous  tissue.  As  a  rule  this  condi- 
tion is  found  in  stomachs  which  are  much  smaller 
than  usual,  and  present  a  thickening  of  their  walls. 
The  size  of  the  organ  in  such  instances  may  be  reduced 
to  that  of  a  big  pear,  and  the  walls  may  attain  a  thick- 
ness of  about  1  to  2  cm.  Brinton  *  has  termed  this 
condition  "cirrhosis  ventriculi,"  while  the  French 
designate  it  "sclerosis  ventriculi."  This  condition  of 
cirrhosis  ventriculi,  however,  may  be  associated  with 

VW.  Brinton  :  "Diseases  of  the  Stomach." 


166 


DISEASES   OF   THE   STOMACH. 


the  first-described  process,  as  the  following  drawing  of 
a  case  I  have  observed  clearly  illustrates. 

Etiology. — Chronic    gastric  catarrh    is    more   fre- 
quently met  with  among  men  than  among  women. 


'■Sr^i 


/. 


Fig.  38.— Cross-Section  through  the  Stomach  Wall  Cof  A.  G.,  with  achylia  gastrica), 
showing  relations  of  the  layers:  a,  mucosa;  ft,  submucosa;  c,  d,  muscularis ;  e, 
serosa.    No  glands  in  the  mucosa.    X  60. 

It  is  often  caused  by  an  irrational  mode  of  living. 
Fast  eating,  resulting  in  imperfect  mastication  of  the 
food;  overloading  the  stomach  with  too  large  quanti- 
ties of  food;  highly  spiced  dishes;  ice-cold  drinks — all 
these  tend  to  irritate  the  stomach,   and  to  cause  a 


CHRONIC   GASTRIC   CATARRH.  167 

catarrhal  condition  of  the  organ.  In  this  country  ice  / 
water  and  fast  eating  are  the  two  principal  causes  of  j 
the  so-called  "American  dyspepsia."  Tea  and  coffee  ' 
taken  in  too  large  quantities  are  also  said  to  cause 
this  trouble.  Alcoholic  drinks,  especially  the  stronger 
ones,  as  whiskey  or  liquors  (among  them  also  stomach 
bitters),  and  the  abuse  of  tobacco  (smoking  and  chew- 
ing, especially  the  latter)  also  frequently  give  rise  to 
this  affection.  But  even  in  people  leading  a  regular 
life  chronic  gastric  catarrh  may  develop,  either  after 
frequently  repeated  attacks  of  the  acute  form  or  after 
the  recovery  from  very  severe  infectious  diseases. 
Thus  typhoid  fever  is  frequently  found  to  be  the 
origin  of  the  affection.  An  unhealthy  condition  of 
the  mouth,  and  more  so  of  the  teeth,  is  liable  to  pro- 
duce gastritis,  for  in  these  instances  the  food  on  the 
one  hand  cannot  be  chewed  thoroughly ;  on  the  other 
hand  it  becomes  impregnated  with  products  of  decom- 
position originating  from  decayed  teeth,  and  in  this 
way  produces  an  undue  irritation  of  the  gastric  mu- 
cous membrane.  Chronic  gastric  catarrh  is  moreover 
found  as  a  secondary  disorder  in  association  with 
many  other  chronic  diseases;  thus,  for  instance,  all 
kinds  of  pulmonary  and  cardiac  affections,  liver  and 
kidney  troubles,  are  frequently  found  to  be  compli- 
cated with  chronic  gastritis.  Likewise  some  constitu- 
tional diseases,  as  for  instance  gout  and  diabetes,  are 
frequently  combined  with  gastritis. 

Symptomatology. — As  a  rule  the  disease  develops 
very  slowly.  The  initial  symptoms  are  not  well 
marked.  After  the  condition  has  lasted  for  a  longer 
period    of    time  the  disturbances  become  more  pro- 


168  DISEASES   OF   THE   STOMACH. 

nounced,  and  a  train  of  many  varied  symptoms  is 
present.  The  patients  frequently  complain  of  an  ab- 
normal taste  in  their  mouths.  They  describe  it  either 
as  salty  or  as  pappy,  in  a  few  instances  as  sour. 
The  appetite  is  ordinarily  diminished,  or,  if  present, 
the  feeling  of  satiation  appears  after  a  few  morsels 
of  food.  After  meals  there  is  a  sensation  of  fulness 
in  the  gastric  region,  and  the  patient  feels  oppressed. 
This  feeling,  if  j)reseut  in  a  higher  degree,  sometimes 
gives  rise  to  symptoms  of  quite  an  alarming  nature. 
Thus  the  patients  complain  of  palpitations  of  the  heart 
and  shortness  of  breath  (asthma  dyspepticum).  In 
some  instances  again  there  appears  a  dizzy  feeling, 
which  is  occasionally  so  severe  that  the  patient  cannot 
occupy  a  standing  position  but  has  to  sit  down  or  lie 
down.  The  oppression  experienced  is  relieved  by 
belching,  but  the  latter  may  occur  so  frequently  as  to 
greatly  annoy  the  patient.  In  fact,  belching  consti- 
tutes  one  of  the  most  frequent  symptoms  of  chronic 
gastric  catarrh.  As  a  rule,  a  quantity  of  odorless  gas 
is  brought  up  by  the  act  of  belching,  although  in  very 
rare  instances  it  may  have  an  unpleasant  odor. 

Pain. — As  a  rule  intense  pains..ara-ahseni.  There 
is  a  mere  sensation  of  discomfort  and  sensitiveness  in 
the  gastric  region,  which  may  increase  after  meals, 
more  especially  after  ingestion  of  coarse  food. 

Pyrosis. — The  patient  may  experience  a  burning 
sensation  at  the  pit  of  the  stomach.  In  this  instance 
a  sour  liquid,  alone  or  mixed  with  food,  often  comes  up 
through  the  oesophagus  into  the  mouth  (regurgita- 
tion). 

Vomiting. — Vomiting    is  not  of  very  frequent  oc- 


CHRONIC   GASTRIC   CATARRH.  169 

cnrrence  in  gastric  catarrh.  It  is  met  with  most  fre- 
quently after  the  morning  meal  or  in  the  morning  on 
arising.  In  the  latter  instance  the  quantity  ejected  is 
quite  small,  and  consists  of  a  watery  fluid  containing 
ijrincipally  mucus.  A  feeling  of  nausea  is  more  fre- 
quently observed. 

Condition  of  the  Bowels. — The  bowels  are  fre- 
quently found  abnormal :  either  they  are  very  con- 
stipated, which  is  quite  the  rule,  or  there  may  exist 
diarrhoea,  or  again  periods  of  diarrhoea  may  alternate 
with  periods  of  constipation. 

Urine. — The  urine  is  scanty,  and  frequently  con- 
tains deposits  of  phosphates  and  urates. 

General  Symptoms. — The  patients  feel  languid  and 
manifest  less  energy  in  the  performance  of  their  work. 
Their  mental  activity  is  frequently  weakened.  They 
often  complain  of  headache,  especially  in  the  morning, 
and  a  heavy  feeling  in  the  limbs.  A  desire  to  yawn  is 
often  met  with,  and  some  patients  assert  that  they 
cannot  breathe  as  deeply  as  they  desire.  In  some  in- 
stances the  flow  of  saliva  is  greatly  increased.  Some- 
times patients  experience  a  constant  irritating  feeling 
in  the  throat,  which  they  seek  to  relieve  by  a  kind  of 
hacking  cough. 

Objective  Signs. — The  general  appearance  of  the 
patient  is,  as  a  rule,  quite  good.  He  looks  well 
nourished,  and  usually  possesses  a  good  panniculus 
adiposus.  Some  patients,  however,  show  black  rings 
around  their  eyes,  notwithstanding  their  being  well 
nourished.  Under  these  circumstances  they  frequent- 
ly have  cold  hands  and  feet,  and  chill  very  easily. 
There  are,  however,  exceptions  to  this  rule,  and  pa- 


170  DISEASES   OF   THE    STOMACH. 

tients  are  sometimes  observed  who  have  lost  consider- 
ably in  weight  and  appear  quite  emaciated  and  thin. 

The  tongue  is,  as  a  rule,  covered  with  a  fairly  thick, 
grayish,  and  moist  coating.  The  margins  of  the 
tongue  show  the  indentations  of  the  teeth.  Either 
there  is  no  offensive  smell  present  in  the  mouth  or,  if 
it  exists,  it  is  due  to  some  imperfection  in  the  condition 
of  the  teeth,  nose,  or  throat. 

The  gastric  region  often  appears  bloated.  On  pal- 
pation it  is  found  to  be  sensitive  to  pressure,  although 
there  is  no  real  pain.  The  splashing  sound  can  be 
easily  produced  when  the  stomach  contains  some 
liquid.  The  size  of  the  organ  is,  as  a  rule,  not 
increased. 

The  gastric  contents :  One  hour  after  Ew aid's 
test  breakfast  the  gastric  contents  show  a  lessened  de- 
gree of  acidity,  and  contain  either  no  free  hydrochloric 
acid  at  all  or  only  small  quantities.  The  pieces  of 
roll  are  not  as  fine  as  normally.  Pepsin  and  rennet  are 
always  present;  erythrodextrin  is  present  only  in 
small  quantities,  while  achroodextrin  and  sugar  are 
abundant.  The  quantity  of  the  gastric  contents  ob- 
tained after  the  test  breakfast  is  either  normal  or 
somewhat  larger  (120-180  c.c).  Mucus  may  be 
present  in  great  quantities  in  the  gastric  contents  of 
some  persons,  while  it  may  be  absent  in  others.  In 
the  former  case  the  gastritis  is  designated  by  the  name 
of  "gastritis  chronica  mucosa."  The  mucus  in  the 
gastric  contents  can  be  easily  recognized  by  its  appear- 
ance. A  glass  rod  dipped  into  the  contents  and  lifted 
in  an  oblique  direction  will  cause  a  part  of  the  mucus 
to  be  drawn  up  in  the  form  of  strings.     The  contents 


CHRONIC    GASTRIC    CATARRH.  171 

pass  very  slowly  through  filter  paper,  and  the  addition 
of'  acetic  acid  to  the  filtrate  will  produce  turbidity. 
In  the  fasting  condition  the  stomach  is  either  found 
empty,  or  it  may  contain  only  a  few  cubic  centimetres 
of  a  turbid  liquid,  consisting  of  mucus,  and  presenting 
either  an  alkaline,  neutral,  or  acid  reaction.  In  the 
latter  instance  free  hydrochloric  acid  may  be  dis- 
covered in  small  quantities.  Microscopically  many 
round  cells  and  some  epithelial  cells  are  found  to  be 
present.  In  washing  out  the  stomach  in  the  fasting 
condition,  the  wash-water,  as  a  rule,  contains  more  or 
less  considerable  quantities  of  mucus.  Instead  of  ex- 
amining the  gastric  contents,  the  vomited  matter,  if 
such  is  present,  can  be  made  use  of  for  testing  the 
chemical  qualities  of  the  gastric  juice.  As  a  rule,  the 
same  conditions  will  prevail  here  as  stated  above 
under  the  examination  of  the  gastric  contents. 

The  motor  function  of  the  stomach  is  either  not  im- 
paired at  all,  or  only  slightly  diminished. 

Absorption. — Most  writers  assert  that  the  absorp- 
tion is  retarded.  It  seems  to  me,  however,  that  this 
rule  does  not  apply  to  all  substances.  On  examining 
the  absorptive  power  in  several  cases  of  chronic  gas- 
tric catarrh  with  the  potassium  iodide  test,  I  could  not 
see  any  marked  departure  from  the  normal. 

I  subjoin  two  cases  of  chronic  gastric  catarrh,  one 
representing  a  mild  and  the  other  a  more  advanced 
form  of  this  affection : 

Case  I. — Mrs.   L.  W ,  about  26  years  of  age, 

suffered  for  about  four  years  from  frequently  recur- 
ring digestive  disturbances  (poor  appetite,  pains  in  the 
region  of  the  stomach  and  in  the  abdomen).     She  had 


173  DISEASES   OP   THE   STOMACH. 

been  treated  by  several  competent  physicians,  some- 
times with  good  results.  Several  months  before  con- 
sulting me  the  general  health  of  the  patient  was 
impaired ;  the  complaints,  however,  had  greatly  in- 
creased during  the  past  six  weeks.  She  suffered  from 
pains  in  the  region  of  the  stomach,  and  could  not  eat 
sufficiently,  for  soon  after  partaking  of  the  food  she 
had  a  sensation  of  being  laced  ;  she  could  not  sleep,  and 
was  troubled  much  with  repeating  and  flatus ;  during 
the  summer  she  lost  in  weight  considerably. 

Status  'py<xsens  :  Patient  has  a  pale  appearance  and 
frail  structure ;  color  of  lips  and  cheeks  pale ;  tongue 
coated  ;  chest  organs  normal ;  abdominal  wall  relaxed ; 
the  abdomen  slightly  distended ;  the  epigastric  region 
somewhat  painful  on  pressure;  the  splashing  sound 
can  be  produced  below  the  left  margin  of  the  ribs 
down  to  a  point  three  fingers'  width  above  the  navel. 

One  hour  after  the  test  breakfast :  HCl  =  0 ;  lactic 
acid  + ;  acidity  =  GO ;  ery throdextrin  +  much ;  mucus 
present. 

When  fasting,  stomach  is  found  empty ;  lavage 
brings  up  very  little  mucus. 

Treatment:  Nux  vomica,  HCl,  gymnastics,  cold 
washing  and  rubbing  of  the  body,  and  direct  gastro- 
faradization. 

Soon  after  the  beginning  of  this  treatment  the  pa- 
tient felt  better;  she  could  partake  of  more  food ;  the 
pains  first  decreased  in  severity,  and  soon  disappeared 
almost  entirely.  The  patient  gained  during  treat- 
ment (six  to  seven  pounds)  and  acquired  a  healthy 
color. 

Case  II. — Henry  K ,  33  years  of  age,  suffered 

for  ten  or  fifteen  years  from  "spitting  of  water."  By 
this  phrase  the  patient  meant  to  express  the  belching 
every  day,  or  at  least  every  other  day,  of  a  consider- 


CHRONIC   GASTRIC   CATARRH.  173 

able  amount  of  a  tasteless  fluid  from  the  stomach  into 
the  mouth,  which  he  then  expectorated.  Sometimes 
this  occurred  ten  or  twelve  times  during  the  day.  For 
the  last  eight  or  nine  months  the  patient  had  this  spit- 
ting after  each  meal.  Appetite  never  good,  although 
the  patient  could  partake  of  each  meal.  When  a  boy 
he  was  strong  and  stout,  but  has  been  thin  since  his 
twentieth  year.  Sleep  good;  bowels  moved  every 
other  day,  but  not  regularly.  During  the  last  thirteen 
years  there  has  been  from  time  to  time  vomiting  {i.e., 
the  ejection  of  the  whole  meal).  Before  the  vomiting 
the  patient  has  a  sensation  of  oppression. 

The  physical  examination  of  the  chest  organs  reveals 
nothing  abnormal.  The  stomach  reaches  down  to 
within  two  fingers'  width  of  the  symphysis,  as  shown 
by  gastrodiaphany  and  splashing  sounds. 

One  hour  after  the  test  breakfast :  HCl  =  0;  acidity 
=  14;  rennet  ferment +.  (Similar  results  have  been 
obtained  by  examination  on  several  other  occasions.) 

Course. — The  duration  of  chronic  gastritis  is  a  very 
long  one. 

Very  frequently  there  are  exacerbations  of  the 
symptoms,  even  when  the  condition  was  apparently 
almost  entirely  subdued.  Indiscretions  in  diet  are 
especially  liable  to  cause  a  recurrence.  Often,  how- 
ever, a  rational  treatment  effects  the  disappearance  of 
all  the  symptoms,  and  the  condition  of  perfect  euphoria 
may  last  for  years  and  years. 

Diagnosis. — In  the  diagnosis  of  chronic  gastritis 
the  following  points  demand  attention : 

1.  The  long  and  progressive  course  of  the  disease. 

2.  The  symptoms  above  described. 

3.  The   decreased   secretion   of   gastric   juice    (low 


174  DISEASES    OF   THE   STOMACH. 

acidity),  wliicli  in  some  may  be  combined  with  an 
undue  amount  of  mucus. 

Differential  Diagnosis. — It  is  quite  easy  to  dis- 
tinguish between  primary  and  secondary  chronic  gas- 
tritis. The  latter  accompanies  many  organic  diseases 
of  vital  organs.  The  recognition  of  the  principal  ail- 
ment shows  the  true  nature  of  the  affection.  It  is 
more  difficult  to  differentiate  between  chronic  gastric 
catarrh  and  other  lesions  of  the  stomach :  ulcer,  can- 
cer, neurosis,  achylia  gastrica.  Chronic  gastritis  is 
never  accompanied  by  very  severe  pains,  and  thus  pre- 
sents a  contrast  to  ulcer  and  cancer.  Absence  of  a 
circumscribed  spot  painful  to  pressure  in  the  gastric 
region  also  speaks  against  ulcer.  There  is  no  hsema- 
temesis,  and  as  a  rule  no  marked  emaciation  in  chronic 
gastritis,  while  in  ulcer  and  cancer  these  two  conditions 
are  frequently  met  with.  It  is  quite  difficult  to  differ- 
entiate between  chronic  gastritis  and  gastric  neuroses 
of  a  depressing  nature.  The  symptoms  may  be  alike 
in  both,  especially  the  diminished  gastric  secretion. 
These  neuroses  may  sometimes  be  recognized  by  the 
discovery  of  other  nervous  symptoms.  Sudden 
changes  in  the  chemical  condition  of  the  gastric  con- 
tents speak  in  favor  of  the  existence  of  a  neurosis. 
Changes  in  the  subjective  symptoms,  their  entire 
disappearance  for  a  few  days,  and  then  their  sud- 
den reappearance,  either  in  the  same  form  as  before 
or  in  a  changed  manner,  are  also  characteristic  of  a 
gastric  neurosis.  Chronic  gastritis,  on  the  other  hand, 
shows,  as  a  rule,  more  or  less  consistency  in  the  con- 
ditions of  the  gastric  juice  as  well  as  of  the  other 
symptoms.     While  changes  in  the  subjective  sensa- 


CHRONIC    GASTRIC    CATARRH.  ITo 

tioDS  of  the  patient  may  occur,  they  are,  however,  less 
abrupt  and  less  pronounced  than  in  the  neurosis. 
Acbylia  gastrica  is  recognized  by  the  total  disappear- 
ance of  gastric  juice,  i.e.,  by  the  absence  of  hydro- 
chloric acid  and  both  ferments,  rennet  and  pepsin. 
Although  chronic  gastritis  may  terminate  in  such  a 
condition  (a  disappearance  of  juice),  it  is  nevertheless 
more  practical  to  separate  achylia  gastrica  from  gas- 
tric catarrh,  as  there  are  several  other  conditions 
which  lead  to  this  affection,  and  as  it  requires  a  differ- 
ent treatment. 

Prognosis. — The  prognosis  of  a  genuine  chronic 
gastritis  is  not  bad.  A  rational  treatment  succeeds, 
as  a  rule,  in  either  curing  or  materially  improving  the 
patient.  The  ailment  is,  however,  by  no  means  of  an 
indifferent  nature;  in  a  certain  measure  we  can  say 
that  the  trouble  is  the  more  serious  the  less  secretion 
there  is  in  the  stomach.  Very  frequently  we  are  not 
able  to  bring  back  the  stomach  to  its  normal  state  of 
secretion,  even  if  we  succeed  in  combating  the  subjec- 
tive symptoms.  Exacerbations  and  relapses  are  also 
liable  to  occur.  For  these  reasons  chronic  gastritis 
must  be  considered  as  a  tedious  affection. 

Treatment. — The  regulation  of  the  diet  is  of  jDrime 
importance  in  the  treatment.  The  dietary  to  be  se- 
lected will  depend  upon  the  severity  of  the  symptoms. 
At  the  beginning,  therefore,  a  light  diet  will  be  called 
for.  The  patient  should  partake  of  four  or  five  meals 
daily.  The  articles  of  food  should  be  given  largely  in 
liquid  and  semi-liquid  form;  viz.,  milk,  kumyss.  mat- 
zoon,  barley,  oatmeal,  and  rice  soups  prepared  in 
milk ;  chicken  soup,  with  an  Qgg  beaten  up  in  it ;  soft- 


176  DISEASES   OF   THE   STOMACH. 

boiled  eggs;  mashed  potatoes;  scraped  meat,  raw  or 
broiled;  toasted  bread,  and  also  FreDch  white  bread 
(not  too  fresh) ;  butter;  tea  and  cacao.  The  quantity 
of  nourishment  for  each  meal  should  neither  be  ex- 
cessively large  nor  too  small. 

Ewald's  bill  of  fare  for  chronic  gastric  catarrh  is  as 
follows: 

Eight  o'clock— 150-200  gm.  of  tea  with   75-100  gm.  of 

stale  white  bread,  toast  or  zwieback. 
Ten  o'clock — 50  gm.  of  white  bread,  10  gm.  of  butter,  50 

gm.  of  cold  meat  or  ham,  occasionally  one  glass  of 

light  wine  or  one-third  litre  of  milk. 
Two  o'clock — 150-200  gm.  of  water,  milk,  or  bouillon  of 

the  white  meats,  100-125  gm.  of  meat  or  fish,  80-100 

gm.  of  vegetables,  80  gm.  compot. 
Four  or  five  o'clock — one-fourth  to  one-third  litre  of  warm 

milk  (occasionally  mixed  with  cacao  or  coffee) . 
Seven  to  eight  o'clock — 200  gm.  of  soup  or  pap,  50  gm.  of 

white  bread,  10  gm.  of  butter. 
Occasionally  at  ten  o'clock — 50  gm.  wheaten  bread  (bis- 
cuits or  zwieback),  one  cup  of  tea. 

My  own  bill  of  fare  for  the  first  week  of  treatment 
is  as  follows : 

Eight  o'clock : 

Two  eggs, 

Two  ounces  of  French  white  bread,    . 
One-half  ounce  of  butter,     . 
One  cup  of  tea  (100  gm.  of  tea,  150  gm.  of  milk) 
Sugar  10  gm.  (3iiss.),        .... 

Half -past  ten  o'clock : 

Kumyss  or  matzoonor  milk,  250  gm.  (  3  viii 

Crackers,  30  gm.  (one  ounce),     . 

Butter,  20  gm.  (3  v.),  .... 


Calories. 

.      160 

156 

107 

Ik) 

101 

40 

i),       168 

.     107 

163 

CHRONIC    GASTRIC   CATARRH.  17? 

Calories. 

Half -past  twelve  o'clock : 

Two  ounces  of  tenderloin  steak  or  the  white  meat 

of  chicken,        .         .         .         .         .         .         .  72 

Mashed  potatoes,  or  thick  rice,  100  gm.  (  3  iii,  -J^),  127 

White  bread,  two  ounces,   .....  153 

Butter,  one-half  ounce,        .         .         .         .         .  107 

One  cup  of  cacao,  200  gm.  (  i  vi.  f),           .         .  101 

Half -past  three  o'clock: 

The  same  as  half -past  ten,  .....     438 

Half-past  six  o'clock : 

Farina,  hominy,  or  rice  boiled  in  milk,  one  plate- 
ful, 250  gm.  (  3  viii.  i),  ....     440 

Two  scrambled  eggs,  .         .         .         .         .         .160 

Bread,  two  ounces,      ......     156 

Butter,  one-half  ounce,        .....     107 

2,863 
The  patient  having  been  kept  on  this  diet  for  a  week 
or  two,  the  diet  must  be  gradually  changed  to  one 
suitable  for  the  lighter  forms  of  chronic  gastritis. 
Here  the  following  rule  will  apply :  The  diet  should 
correspond  as  nearl}"  as  possible  to  the  common  mode 
of  living.  In  this  way  the  distribution  of  the  meals 
should  be  arranged  according  to  the  customs  prevail- 
ing in  those  places  in  which  the  patients  live.  All 
foods  derived  fi'om  the  vegetable  kingdom  should  be 
given  in  large  portions,  while  the  quantity  of  meat 
should  be  somewhat  limited.  In  order  to  permit  the 
patient  to  have  a  greater  variety  in  his  food,  it  is  best 
not  to  point  out  a  few  articles  he  should  eat,  but  to 
mention  only  those  he  should  avoid.  Forbid  meat 
with  very  tough  fibres,  meat  from  too  old  animals  or 
too  fresh  meat  (right  after  slaughtering),  meat  that 

contains  too  much  fat,  like  pork ;  forbid  sausages,  lob- 

13 


178  DISEASES   OF   THE   STOMACH. 

ster,  salmon,  chicken  salad,  mayonnaise,  cucumbers, 
pickles,  cabbage,  strong  alcoholic  drinks  like  liquors. 
It  must  be  impressed  upon  the  patient  to  masticate  the 
food  thoroughly,  to  eat  slowly,  not  to  think  of  busi- 
ness during  meals,  and  to  stop  eating  before  the  sen- 
sation of  satiety  appears.  The  latter  advice  is  only 
necessary  in  persons  who  are  accustomed  to  high 
living. 

Hygienic  Regimen. — Besides  the  diet  it  is  of  im- 
portance that  the  patient  should  lead  a  rational 
hygienic  life.  The  business  hours  should  not  be  too 
long,  and  plenty  of  exercise  should  be  advised.  Walk- 
ing, driving,  horseback  and  bicycle  riding,  rowing, 
are  all  to  be  highly  recommended.  It  is,  however, 
necessary  to  tell  the  patients  not  to  overexert  them- 
selves. Gymnastic  exercises  at  home,  especially  v/ith 
an  exercising  machine,  are  also  in  place.  I  usually 
tell  the  patient  to  exercise  in  the  morning  for  about 
ten  minutes.  A  cold  sponge  bath  on  arising,  and  a 
thorough  rubbing  of  the  skin  with  a  thick  rough  towel, 
are  valuable.  It  is  furthermore  of  importance  to  see 
that  the  patients  live  in  well-ventilated  rooms.  A 
prolonged  stay  in  places  where  there  is  much  smoke 
(restaurants;  should  be  prohibited. 

In  many  instances,  the  regulation  of  diet  and  hy- 
giene will  be  sufficient  to  improve  the  patient's  condi- 
tion. The  direct  means,  however,  of  accomplishing 
this  purpose  comprise  the  four  following: 

1.  Lavage;  2.  Electricity;  3.  Mineral  springs;  •!. 
Medicaments. 

1.  Lavage. — In  most  cases  of  chronic  gastric  catarrh 
washing  out  of  the  stomach  will  prove  beneficial.     The 


CHRONIC    GASTRIC    CATARRH.  179 

mucous  form  of  gastritis  is  especially  benefited  by  this 
means.  The  lavage  should  be  performed  in  the  morn- 
ing in  the  fasting  condition  of  the  patient.  Pure, 
lukewarm  water  should  be  used  in  this  procedure. 
Occasionally  a  small  quantity  of  common  table  salt 
may  be  added.  The  lavage  should  be  employed  every 
other  day  for  a  period  of  two  or  three  weeks.  It  is 
not  advisable  to  entrust  this  procedure  to  the  patient, 
as  he  is  apt  to  overdo  it. 

2.  Electricity. — In  order  to  stimulate  the  stomach, 
the  faradic  current  has  frequently  been  made  use  of. 
While  at  first  the  percutaneous  method  of  electrifying 
the  stomach  was  used,  lately  the  direct  or  intragastric 
mode  of  electrization  has  been  more  often  employed. 
For  percutaneous  electrization  a  very  large  sjDouge 
electrode  (IS  by  12  cm.)  is  put  over  the  abdomen, 
covering  the  entire  gastric  region,  while  the  other, 
smaller  electrode  (diameter  about  5  cm.)  is  held  to  the 
left  of  the  seventh  dorsal  vertebra. 

Intragastric  electrization  is  by  far  more  effectual 
and  therefore  preferable  to  the  percutaneous  method. 
Here  the  current  reaches  the  inside  of  the  stomach  in 
undiminished  strength,  while  in  the  percutaneous 
mode  of  electrization  the  greater  part  of  the  current 
is  distributed  over  the  skin  and  muscles  of  the  ab- 
dominal cavity,  and,  if  any,  only  a  small  fraction  of 
the  current  reaches  the  gastric  mucosa.  The  method 
of  intragastric  electrization  has  been  described  above 
(page  llrtt).  In  chronic  gastritis  the  faradic  current 
should  be  employed.  By  means  of  intragastric  faradi- 
zation all  the  subjective  symptoms  frequently  disap- 
pear, and  if  the  electric  treatment  is  administered  over 


180  DISEASES   OF   THE   STOMACH. 

a  period  coveriDg  from  two  to  three  months  there  is 
often  a  lasting  amelioration  in  the  condition  of  the 
patient.  The  cases  most  suitable  for  this  mode  of 
treatment  are  those  forms  of  chronic  gastric  catarrh 
in  which  not  much  mucus  appears  in  the  stomach. 

3.  Mineral  Springs. — There  are  many  mineral 
springs,  the  waters  of  which  have  a  decided  beneficial 
influence  upon  the  chronic  gastric  catarrh.  Many  pa- 
tients going  to  these  watering-places  and  drinking  the 
waters  at  the  springs  either  become  improved  or  are 
entirely  cured.  While  these  waters  may  be  taken 
with  some  benefit  at  home,  still  a  sojourn  at  a  water- 
ing-place combines  many  other  curative  factors  besides 
the  water:  the  perfect  rest  and  absence  of  all  cares, 
and  the  fresh  and  invigorating  country  air. 

The  mineral  springs  which  are  most  useful  in  this 
affection  are  the  following: 

1.  Saline  springs  containing  sodium  chloride,  and 
small  or  large  amounts  of  carbonic  acid  gas:  Wies- 
baden (Kochbrunnen — temperature,  69°  C. ;  sodium 
chloride,  0.68  per  cent),  Kissingen  (Racoczi  and  Pan- 
dur — temperature,  10.7°  C. ;  sodium  chloride,  0.55  per 
cent),  Homburg  (Elisabethbrunnen  —  temjDerature, 
10. 6°  C;  sodium  chloride,  0.98  per  cent),  Soden  (nu- 
merous sodium  chloride  [0.24-1.4  per  cent]  springs 
containing  carbonic  acid  gas,  of  different  tempera- 
tures [15°-30°  C.]),  Saratoga  (Congress  Spring). 

2.  Alkaline  saline  springs,  containing  sulphate  of 
sodium,  carbonate  of  sodium,  sodium  chloride,  and  car- 
bonic acid  gas  in  large  amounts:  Carlsbad  (there 
are  twelve  springs,  each  possessing  about  the  same 
quantity  of  salts:     Sulphate  of  sodium,  0.23  percent; 


CHRONIC   GASTRIC   CATARRH.  181 

bicarbonate  of  sodium,  0.2  per  cent;  sodium  chloride, 
0.1  per  cent;  carbonic  acid  gas),  Marienbad  (Kreuz- 
brunnen  and  Ferdinandsbrunnen,  0.5  per  cent  sulphate 
of  sodium),  Saratoga  (Hawthorne  Spring). 

In  most  instances  the  first  group  of  springs  (saline) 
are  to  be  recommended.  The  second  group  of  springs 
(alkaline  saline)  are  to  be  employed  in  patients  in 
whom  constipation  forms  a  very  marked  symptom. 
The  use  of  these  springs  should,  however,  not  be  ex- 
tended over  too  long  a  period  of  time.  Patients  of  a 
nervous  character  should  not  partake  of  these  purga- 
tive waters.  Both  the  saline  and  alkaline  saline 
waters  can  be  taken  at  home,  if  the  patient  is  not  able 
to  go  to  the  springs.  It  is  best  to  have  the  patient 
drink  about  a  tumblerful  of  either  of  the  waters  early 
in  the  morning  when  arising,  about  an  hour  before 
breakfast. 

4.  Medicaments. — The  medicaments  were  used  to 
a  much  greater  extent  in  the  treatment  of  chronic  gas- 
tric catarrh  in  olden  times  than  nowadays.  At  pres- 
ent we  have  learned  to  pay  more  attention  to  diet,  to 
hygiene,  and  to  the  mechanical  means  of  treating  the 
stomach.  In  some  instances,  however,  the  medica- 
ments are  also  serviceable.  Among  these,  hydro- 
chloric acid  is  one  that  is  most  frequently  employed  in 
this  affection.  The  idea  of  supplementing  the  defi- 
ciency of  gastric  juice  by  this  acid,  which  forms  its 
principal  element,  is  quite  natural.  Leube '  first  in- 
troduced this  medicament  into  the  therapeusis  of 
chronic  gastritis  and  Ewald '  likewise  recommends  it 

'  Leube  :  "  Die  Krankheiten  des  Magens und  Darms. "    Ziemssen's 
"Handbuchderspec.  Patholog.  undTherapie,"  Bd.  vii.,  Heft  2,  p.  75. 
2  Ewald  :  I.  c,  p.  343. 


1)S2  DISEASES    OF    THE    STOMACH. 

very  highly.  He  says:  ''In  all  cases  where  a  diminu- 
tion or  absence  of  hydrochloric  acid  has  been  deter- 
mined, i.e.,  in  all  cases  of  chronic  gastritis,  it  is  there- 
fore to  be  given  preferably  as  the  dilute  hydrochloric 
acid  of  the  pharmacoi^oeia  in  large  quantities,  and  cer- 
tainly in  larger  doses  than  have  thus  far  been  recom- 
mended." The  best  way  to  administer  this  medica- 
ment is  to  give  it  in  the  form  of  drops,  six  to  twelve 
of  the  dilute  hydrochloric  acid  in  a  glassful  of  water, 
to  be  taken  three  times  a  day  half  an  hour  after  meals, 
not  drinking  the  whole  glassful  of  water  at  once,  but 
one-third  at  a  time  at  intervals  of  one-quarter  of  an 
hour  or  half  an  hour.  Ewald  advocates  larger  doses 
than  these,  namely,  forty  to  sixty  drops  of  the  dilute 
hydrochloric  acid  three  times  daily. 

Pepsin  used  to  be,  and  is  yet  very  frequently  given 
in  combination  with  hydrochloric  acid,  the  dose  being 
about  half  a  gram  three  times  daily.  Most  writers, 
however,  concur  in  the  absolute  inefficacy  of  this  drug, 
and  for  two  reasons,  viz..  (1 »  in  most  instances «ven  of 
diminished  gastric  secretion  (diminished  acidity)  there 
is  yet  an  abundant  quantity  of  pepsin  present;  {'!) 
most  pepsins  that  are  in  the  market  do  not  by  any 
means  show  as  strong  digestive  properties  as  the  true 
pepsin  of  the  stomach. 

Formerly  I  was  in  the  habit  of  employing  hydro- 
chloric acid  either  alone  or  in  combination  with  pepsin 
quite  frequently.  Of  late  years,  however,  I  have  en- 
tirely abandoned  the  use  of  pepsin,  and  greatly  re- 
stricted the  administration  of  hydrochloric  acid.  The 
reason  for  this  is  based  upon  the  belief  that  the  means 
which  serve  for  the  digestion  and  utilization  of  food 


CHRONIC   GASTRIC   CATARRH.  183 

by  the  organism  are  certainly  not  limited  to  the  stom- 
ach, but  that  the  principal  part  of  this  process  takes 
place  in  the  intestines.  The  artificial  means  of  aiding 
digestion  are  certainly  not  necessary,  the  more  so  since 
if  employed  for  long  periods  of  time  they  frequently 
become  injurious  to  a  certain  extent.  Every  organ  is 
strengthened  by  activity  and  weakened  by  the  lack  of 
exercise.  Predigested  foods,  or  medicaments  which 
contain  the  active  principles  of  the  gastric  juice  and 
serve  to  replace  the  work  done  by  the  stomach,  will,  in 
the  course  of  time,  have  a  deteriorating  effect  upon  the 
gastric  functions.  The  stomach  will  grow  weaker  and 
weaker  the  more  artificial  gastric  juice  is  poured  into  it, 
and  the  finer  and  more  subtle  the  nourishments  that  are 
allotted  to  it.  While  I  do  not  advocate  the  frequent 
use  of  hydrochloric  acid  and  pepsin,  I  am  strongly  in 
favor  of  the  administration  of  the  so-called  bitter  medi- 
caments (amara),  condurango,  quassia,  gentian,  kino, 
calumba,  and  nux  vomica,  which  must  be  considered 
as  effective  stimulants  of  the  gastric  functions.  Al- 
though the  physiological  efficacy  of  these  drugs  has 
been  disputed  by  several  writers  (Tschelzoff  and  Ja- 
worski),*  empirical  experience,  however,  speaks  highly 
in  their  favor,  and  their  use  should  certainly  not  be 
neglected.  There  is  no  doubt  that  condurango,  quas- 
sia, and  nux  vomica  increase  the  appetite,  and  in  this 
way  make  the  stomach  fit  to  receive  more  food  and 
thus  raise  the  nutrition  of  the  organism.  I  usually 
give  fluid  extract  of  quassia,  calumba,  or  condurango 

'  Jaworski :  "  Experimenteller  Beitrag  zur  Wirkung  und  thera- 
peutischen  Anwendung  der  Amara  und  der  Galle. "  Zeitschr,  f. 
Therapie,  1886,  No.  23.  ' 


184  DISEASES   OF   THE   STOMACH. 

in  doses  of  twenty  drops  three  times  daily,  or  tincture 
of  nux  vomica,  either  alone  in  doses  of  ten  drops  three 
times  daily,  or  in  combination  with  tne  above  drugs. 
All  these  medicaments  must  be  taken  about  a  quarter 
of  an  hour  before  meals  in  about  a  tablespoonful  of 
water  or  wine.  Creosote  I  frequently  give  in  the  gas- 
tritis of  phthisical  patients. 

I^    Creosote, 5-0 

Compound  tincture  of  gentian,        .        .        .        .10.0 
S.  Eight  drops  in  half  a  glassful  of  milk  three  times  daily,  half 
an  hour  after  meals. 

Orexin  may  also  be  given  for  the  same  purpose: 

I^  Orexin.  basic, 0.3  (gr.  iiiss.) 

D.   in  wafers  t.  d. ,  No.   15.     Sig.  One  wafer  in  a  cup  of  bouil- 
lon half  an  hour  before  meals  twice  daily. 

Chronic  gastric  catarrh  is  frequently  combined  with 
constipation,  and  it  will  be  necessary  to  speak  about 
the  management  of  this  complication.  As  a  rule,  I 
would  say  that  the  less  medicaments  used  to  combat 
this  affection  the  better.  The  means  available  for  this 
trouble  are:  You  must  tell  the  patient  to  go  to  the 
water-closet  in  the  morning  at  a  certain  hour,  to  avoid 
much  straining,  and  not  to  bother  about  the  bowels 
any  more  during  the  whole  day,  even  if  there  were  no 
movement,  and  not  to  go  to  the  water-closet  unless 
there  be  a  strong  inclination  for  it  until  the  following 
morning.  Frequently  this  alone  is  sufficient  to  secure 
regularity  of  the  bowels  after  a  while. 

The  diet  can  also  be  arranged  in  such  a  manner  as 
to  facilitate  movements  of  the  bowels.  All  foods 
which  contain  a  large  percentage  of  cellulose  (undi- 
gested  matter)   increase  the  quantity  of  faeces,   and 


CHKONIC   GASTEIC   CATAKRH.  185 

thereby  effect  a  stronger  peristalsis  of  the  large 
bowels.  All  kinds  of  green  vegetables  (spinach,  as- 
paragus, green  peas)  and  rye  bread  are  therefore  very 
suitable.  Many  organic  acids  possess  the  property  of 
increasing  intestinal  peristalsis.  Almost  all  kinds  of 
fruits  contain  a  certain  quantity  of  these  organic  acids, 
and  act  like  mild  aperients.  The  use  of  cooked  pears, 
stewed  or  baked  apples,  stewed  prunes,  is  in  many  in- 
stances effective.  Ewald  recommends  a  mixture  of 
two  parts  of  prunes  to  one  part  of  dried  figs.  The 
taste  is  agreeable  and  the  cathartic  action  mild.  The 
custom  of  eating  an  orange  in  the  morning  for  its  lax- 
ative effect  is  well  known.  To  these  dietary  remedies 
we  may  also  add  the  use  of  a  glassful  of  either  very 
cold  or  warm  water,  or  of  a  glass  of  milk  on  arising, 
in  the  fasting  condition.  There  are  many  persons  in 
whom  one  of  these  latter  means  produces  a  good  move- 
ment of  the  bowels. 

In  cases  where  the  above  dietary  remedies  do  not 
suffice,  the  administration  of  a  mild  cathartic  is  not  out 
of  place.  Ehubarb  and  cascara  sagrada  are  chiefly 
in  use.  The  former  is  given  either  in  substance  or  in 
the  form  of  a  tincture,  fifteen  to  thirty  drops;  the 
latter  in  the  form  of  the  fluid  extract,  fifteen  to 
twenty-five  drops  twice  daily.  Aloes  and  podophyllin 
should  be  used  only  in  the  severer  forms  of  constipa- 
tion.    I  frequently  give  the  following  pills: 

E  Podophyllin,         .  ....         0.3   (gr.  r.) 

Extract  of  nux  Tomica, 

Extract  of  Calabar  bean,  .         .         .  aa  0.5  (gr.  Tiij.) 

M.  f.  cum  extr.  gentian,  et  pulv.  liq.  q.  s.  pil.  No.  30.     S.  One 
pill  twice  a  day. 

The  so-called  Hamburg  tea  is  also  very  efficacious. 


186  DISEASES   OF   THE    STOMACH. 

All  of  these  remedies  should  not  be  used  for  too  long 
a  time,  and  the  patients  should  always  accustom  them- 
selves to  get  along  with  fewer  of  these  remedies,  and 
ultimately  without  them.  In  cases  in  which  there  is 
atony  (weakness)  of  the  large  intestine,  the  use  of 
enemata  is  indicated.  One  quart  of  lukewarm  water 
with  a  teaspoonful  of  salt  is  injected  into  the  rectum 
by  means  of  a  fountain  syringe  provided  with  a  soft- 
rubber  tube.  These  injections  should  be  made  once  a 
day,  always  at  the  same  hour,  and  continued  for  about 
two  weeks.  The  use  of  glycerin  suppositories,  or  of 
a  small  quantity  of  glycerin  in  water  (one  teaspoonful 
to  four  or  five  tablespoon fuls  of  water)  injected  into 
the  rectum,  will  be  required  only  occasionally. 


CHAPTEE  VI. 

ORGANIC     DISEASES     WITH    CONSTANT     hB- 

SIONS.— Continued. 

Ulce?^  of  the  Stomach. 

Synonyms. — Ulcus  pepticum  seu  rodens;  ulcus  ven- 
triculi  rotundum ;  ulcus  simplex;  ulcus  ventriculi 
chronicum  perforans. 

Definition. — Gastric  ulcer  ia  a  disease  characterized 
by  a  more  or  less  deep  destruction  of  the  mucous  mem- 
brane of  the  stomach,  exhibiting  no  tendency  to  heal- 
ing, and  attended  with  symptoms  of  pain,  vomiting, 
and  hemorrhage.  Cruveilhier '  in  1829  was  the  first 
to  describe  this  affection. 

Etiology.  — The  etiology  of  ulcer  of  the  stomach  has 
not  yet  been  definitely  elucidated.  Age  and  sex  seem 
to  play  a  prominent  part  in  its  development.  It  is  of 
quite  frequent  occurrence.  According  to  Brinton  "^  ul- 
cer of  the  stomach  is  found  (either  open  or  cicatrized) 
in  about  five  per  cent,  of  persons  dying  from  all  causes. 
He  further  states  that  ulcer  is  more  frequent  in 
the  female  than  in  the  male  sex,  the  proportion  being 
nearly  as  two  to  one.  As  regards  age,  the  liability  of 
an  individual  to  become  the  subject  of  gastric  ulcer 
gradually  rises  from  what  is  nearly  zero  at  the  age  of 
ten  to  a  high  rate,  which  it  maintains  through  the 

*  Cruveilhier:  "Anatomie  pathologique, "  1829-1835,  Livraison  x. 
2  W.   Brinton  :  I.  c. 


188  DISEASES   OF   THE   STOMACH. 

period  of  middle  life  at  the  end  of  which  it  again  as- 
cends to  reach  its  maximum  at  the  extreme  age  of 
ninety.  Ulcer  of  the  stomach  is  especially,  though 
not  exclusively,  a  disease  of  middle  and  advanced  life. 
According  to  Ewald,'  ulcer  of  the  stomach  occurs  most 
frequently  between  the  twentieth  and  fortieth  years, 
while  its  mortality  is  highest  between  the  ages  of  forty 
and  sixty. 

The  frequency  of  ulcer  of  the  stomach  seems  to  vary 
in  different  localities.  Thus  Berthold  '  gives  the  per- 
centage of  ulcer  of  the  stomach  for  Berlin  as  2.7  per 
cent. ;  Nolte  for  Munich  as  1.23;  Gries  for  Kiel  as  8.3; 
Stark  for  Copenhagen  as  13.  Von  Sohlern  '  has  lately 
called  attention  to  the  fact  that  the  Eoen  Mountains 
and  the  Bavarian  Alps  (Germany)  and  the  greater  part 
of  Eussia  are  nearly  exempt  from  gastric  ulcer.  He 
further  stated  that  the  inhabitants  of  these  territories 
exist  almost  exclusively  on  a  vegetable  diet.  As  such 
a  diet  is  very  rich  in  potassium  salts  (containing  nearly 
one-third  more  of  this  salt  than  a  mixed  diet),  and  as 
the  red  blood  cells  are  to  be  regarded  as  the  chief  car- 
riers of  potassium,  von  Sohlern  claims  that  this  in- 
creased amount  of  potassium  represents  the  cause  of 
the  relative  immunity  of  the  above-mentioned  inhabi- 
tants from  ulcer  of  the  stomach.  On  the  basis  of  this 
theory,  von  Sohlern  recommends  the  administration  of 
potassium  salts  and  of  foods  rich  in  vegetable  matter 
as  a  prophylactic  measure  against  ulcer.  His  theory, 
however,  lacks  the  support  of  examination  of  the  blood 

'C.  A.  Ewald:  I.  c,  p.  234. 

2 Cited  from  Ewald  :  "Diseases  of  the  Stomach,"  p.  233. 
3  Von  Sohlern  :  "Der  Einfluss  der  Ernahrung  auf  die  Entstehung 
des  Magengeschwiirs. "     Berl.  klin.  Wochenschr. ,  1889,  No.  14. 


ULCER    OF    THE    STOMACH.  189 

which  alone  could  prove  the  correctness  of  the  above 
statement. 

It  has  been  furthermore  asserted,  especially  by  the 
English  writers,  that  the  frequency  of  gastric  ulcer 
is  greatly  dependent  on  the  various  callings  of  life. 
Thus  every  one  is  familiar  with  the  belief  that  cooks 
are  especially  subject  to  this  malady.  Shoemakers, 
porcelain  makers,  etc.,  are  also  mentioned  as  frequent 
sufferers  from  ulcer.  These  statements,  however,  are 
not  based  on  correct  data.  Ewald,  for  instance,  is  of 
the  opinion  that  even  in  cooks  gastric  ulcer  is  not 
more  common  than  in  other  people. 

Numerous  writers  have  endeavored  to  study  the  eti- 
ology of  ulcer  by  the  way  of  experiments  on  animals. 
They  have  produced  lesions  of  the  gastric  mucosa  by 
cutting  out  a  piece  of  the  inner  layer  or  by  subjecting 
it  to  different  caustic  chemicals,  but  the  investiga- 
tions of  Griffini  and  Vassale '  showed  that  the  mucous 
membrane  of  the  stomach  of  such  animals  quickly  re- 
places the  defect  experimentally  produced  and  that 
after  a  short  while  the  lesion  is  entirely  healed.  Thus 
these  acute  defects  of  the  mucous  membrane  cannot 
properly  be  called  ulcers,  for  they  show  no  tendency 
to  spread. 

From  these  experiments  it  has  been  concluded  that 
in  the  production  of  the  gastric  ulcer  there  must  be 
not  only  a  lesion  of  the  mucosa,  but  also  some  anomaly 
in  the  condition  of  the  blood.  Quincke  and  Daettvyler " 
made  animals  anaemic  by  venesection  and  produced 

'  Griffini  imd  Vassale  :  "  Beitrage  zur  patholog.  Anat. "  von  Ziegler 
und  Nauwerck,  Bd.  3,  Heft  5,  p.  425. 

^  Quincke  und  Daettvyler  :  Correspondenzbl.  f.  Schweizer  Aerzte, 
1875,  p.  101. 


190  DISEASES   OF   THE   STOMACH. 

lesions  in  the  gastric  mucosa.  In  these  instances  the 
defect  did  not  heal  and  a  condition  similar  to  a  real 
ulcer  was  established.  In  some  of  the  animals  even 
perforation  of  the  ulcer  took  place.  Koch  and  Ewald  ' 
produced  gastric  hemorrhages  in  animals  by  section  of 
the  spinal  cord.  By  introducing  one-half-per-cent 
solution  of  hydrochloric  acid  into  their  stomachs  deep 
ulcers  arose.  Silbermann  ^  introduced  substances  into 
the  circulation  which  disintegrated  the  blood  cor- 
puscles and  produced  hsemoglobinsemia.  Here  also 
the  artificial  defect  of  the  gastric  mucosa  healed  very 
tardily,  and  presented  a  similar  aspect  to  a  real  ulcer. 
There  is  no  doubt  that  the  above  experiences  gained 
by  experiments  on  animals  apply  also  to  the  human 
being.  Acute  lesions  of  the  gastric  mucosa  in  man 
very  frequently  occur  and  heal  very  rapidly  without 
any  ill  effects.  Clinically  we  know  of  cases  in  which 
a  trauma  in  the  gastric  region  produced  hemorrhage 
by  causing  a  tear  in  the  gastric  mucosa.  In  a  few 
days,  however,  the  patients  recovered  without  present- 
ing any  gastric  symptoms  whatever  at  a  subsequent 
period.  Old  English  literature  contains  several  re- 
ports of  cases  in  which  persons  had  swallowed  knives 
which  had  passed  the  whole  digestive  tract  without 
presenting  any  palpable  symptoms.  One  of  the  most 
striking  instances  is  that  reported  by  Dr.  Marcet '  and 
mentioned  by  Ewald.  "  In  the  year  1799  an  American 
sailor  saw  a  juggler  in  Havre  perform  the  trick  of 
knife  swallowing.     Returning  to  his  vessel  somewhat 

'C.  A.  Ewald:  "Klinik  der  Verdauungskrankheitec,"  1.  Theil. 
3.  Aufl.,  p.  122. 

*  Silbermann:  Deutsche  med.  Wochenschr. ,  1886,  No.  29. 
3  Marcet :  Medico-Chirurgical  Transactions,  vol.  xii. ,  p.  72. 


ULCER  OF  THE   STOMACH.  191 

intoxicated  he  was  foolhardy  enough  to  try  to  swallow 
his  open  pocket  knife,  and  succeeding  in  this,  he  ate 
three  more.  Three  passed  off  in  the  stool  during  the 
next  few  days,  but  one  disappeared  forever.  One  eve- 
ning, six  years  later,  he  again  swallowed  portions  of  six 
knives,  but  this  time  not  without  unpleasant  though 
very  transient  results,  on  account  of  which  he  was' ad- 
mitted to  an  hospital.  He  did  this  frequently  till  he 
had  swallowed  about  thirty-five  knives.  Finally  he 
was  taken  seriously  ill  and  he  died  in  Guy's  Hospital 
in  London  in  1809.  In  the  stomach  some  thirty  pieces 
of  blades,  in  parts  markedly  corroded,  together  with 
handles,  were  found ;  two  blades  in  the  colon  and  rec- 
tum which  were  placed  transversely  and  had  perforat- 
ed the  intestinal  wall  (and  that  without  causing  peri- 
tonitis 1),  but  no  recent  or  old  ulcers  of  the  stomach  or 
any  remains  of  them."  In  this  as  in  other  instances 
undoubtedly  the  gastric  wall  had  suffered  considerable 
injury  but  quickly  regained  its  normal  state. 

A  similar  instance  of  a  grave  lesion  of  the  gastric 
mucosa  without  any  ill  effects  I  had  the  opportunity  to 
witness  myself,  and  it  might  be  worth  while  briefly  to 
describe  it. 

A  boy  of  eleven  years,  suffering  from  epilepsy,  dur- 
ing one  of  his  attacks  fell  from  a  window  on  the  first 
floor  of  the  house  into  the  yard,  striking  the  stone 
pavement  with  his  abdomen.  He  was  found  uncon- 
scious and  brought  up  into  his  room,  where  he  re- 
mained in  this  condition  for  about  an  hour.  Upon 
thorough  examination  no  traumatic  lesions  of  the 
skull  could  be  discovered;  his  nose  did  not  bleed,  nor 
was  any  blood  found  in  his  mouth.     About  two  hours 


192  DISEASES   OF   THE   STOMACH. 

after  his  fall  he  suddenly  vomited  over  a  pint  of  fresh 
blood  partly  mixed  with  food.  Six  hours  afterward 
about  the  same  quantity  of  blood  w^as  again  brought 
up.  On  palpation  there  was  no  pain  in  the  gastric 
region.  The  boy  was  kept  quiet  for  a  few  days  and 
quickly  recovered.  Even  during  his  stay  in  bed  he 
never  complained  of  pain.  Afterward  he  could  eat 
everything  and  remained  entirely  free  from  any  gas- 
tric symptoms. 

Analogous  to  the  above  experiments  on  animals 
which  had  been  rendered  anaemic,  we  also  find  gastric 
ulcer  quite  frequenth'  in  chlorotic  individuals,  and  it 
may  be  readily  imagined  that  many  lesions  of  the  gas- 
tric mucosa  which  would  otherwise  remain  without  ill 
effects  are  prevented  from  healing  by  the  depreciated 
condition  of  the  blood  and  become  converted  into 
ulcers.  It  is,  however,  impossible  to  say  that  this 
theory  would  apply  to  all  cases  of  ulcer  of  the  stomach, 
for  very  often  we  find  this  affection  in  people  who  are 
a  picture  of  health,  and  whose  blood  condition  is  ap- 
parently without  any  anomalies. 

Other  Theories  as  to  the  Origin  of  Gastric  Ulcer. — 
As  is  well  known,  erosions  of  the  gastric  mucosa  are 
found  in  chronic  gastritis  and  in  other  diseases  compli- 
cated with  disturbances  of  circulation.  The  origin  of 
erosions  is  explained  by  Harttung'  in  the  following 
way :  The  contraction  of  the  muscularis  of  the  stomach 
produces  an  arrest  of  the  circulation  in  the  rugae  with 
intense  congestion  in  the  veins  and  capillaries,  which 
in  turn  gives  rise  to  hemorrhages  into  the  mucous 
membrane.     Hemorrhagic  infiltration  of  the  mucous 

'  O.  Harttung  :  "  Ueber  Fatenblutungen  und  hamorrhagiscbe 
Erosionen."     Deutsche  iiied.   Wochenschr. ,  1890,  No.  38,  p.  8-47. 


ULCER   OF   THE   STOMACH.  193 

membrane  arises,  in  consequence  of  which  the  latter 
receives  little  or  no  fresh  circulating  blood,  and  very 
soon  succumbs  to  the  digestive  effects  of  the  gastric 
juice.  In  this  way  the  decay  and  the  destruction  of 
the  tissue  and  the  hemorrhagic  erosion  are  produced. 
These  erosions  are  superficial  defects  of  the  gastric 
mucosa,  extending  as  a  rule  not  deeper  than  half 
its  thickness.  Eokitansky,'  and  subsequently  Eind- 
fleisch''  and  Key,"  established  the  theory  that  the  ulcer 
arises  from  the  further  development  of  an  erosion 
(hemorrhagic  erosion). 

The  view,  however,  that  there  is  a  difference  in  de- 
gree but  not  in  type  between  erosion  and  ulcer  of  the 
stomach  is  not  correct.  Langerhans*  based  his  op- 
position to  this  theory  on  his  experience  gained  in  au- 
topsies. I '  have  shown  that  the  diagnosis  "erosions 
of  the  stomach"  can  be  made  clinically,  and  stated 
that  in  none  of  the  cases  observed  by  me  an  ulcer  de- 
veloped. Virchow  "  first  expounded  the  view  that  the 
ulcerative  process  may  result  from  plugging  up  of  the 
nutrient  artery  of  a  certain  part  of  the  mucosa  either 
hy  an  embolus  or  by  a  thrombus,  and  that  the  infarct 
thus  produced  is  destroyed  by  the  gastric  juice.  In 
this  way  a  circumscribed  defect  arises.  Although 
this  view  has  been  greatly  supported  by  Panum's^  ex- 
periments, who  succeeded  in  producing  emboli  in  the 

^Rokitansky:  "  Lehrbuch  der  patholog.  Anatomie. " 
^  Rindfleisch  :  "Lehrbuch  der  patholog.  Anatomie." 
2  Axel  Key  :  Gurlt-Virchow's  Jahresb. ,  1871. 
"* Langerhans  :  Virchow 's  Arch.,  Bd.  124,  p.  373. 
5  Max  Einhorn  :  Medical  Record,  June  23d,  1894. 
^R.  Virchow:  Virchow's  Archiv,  Bd.  v.,  p.  363. 
'  Panum  :  "Experimentelle  Beitrage  zurLehre  von  der  Embolie. " 
Virchow's  Archiv,  Bd.  25,  1862. 
13 


194  DISEASES   OF   THE   STOMACH, 

gastric  arteries  and  ulcers  in  consequence  thereof, 
it  is,  however,  still  undecided  whether  this  etiological 
factor  comes  into  play  in  all  cases  of  gastric  ulcer ;  for 
very  often  the  evidence  of  an  embolized  or  thrombosed 
artery  in  the  neighborhood  of  the  ulcer  is  missing. 
Instead  of  the  older  theory  that  the  diminished  alka- 
linity of  the  blood  is  the  cause  of  the  ulcer  (Pavy'), 
the  newer  one  has  been  generally  accepted:  that  the 
hyperacid  gastric  juice  is  the  most  important  etiologi- 
cal factor  in  the  production  of  ulcer.  Although  this 
theory  had  already  been  expressed  by  Wilson  Fox '  and 
other  of  the  older  writers,  the  credit  of  having  placed 
it  on  a  firmer  basis  belongs  to  the  more  recent  investi- 
gators, Riegel,"  Jaworski  and  Korczynski,'  Ewald ' 
and  Charles  G.  Stockton.*  It  has  been  found  by  these 
authors  that  hyperacidity  of  the  gastric  juice  is,  if  not 
of  constant,  at  any  rate  of  very  frequent  occurrence 
in  gastric  ulcer.  Furthermore,  it  was  ascertained  that 
those  conditions  in  which  gastric  ulcer  is  very  fre- 
quently found  (as,  for  instance,  chlorosis,  anaemia, 
amenorrhoea)  are  also  associated  with  an  hyperacid 
gastric  juice.  From  my  own  experience  I  would  cer- 
tainly say  that  hyperacidity  is  very  often  met  with  in 
gastric  ulcer.     There  are,  however,  exceptions  to  this 


'Pavy:  "On  Gastric  Erosion."  Guy's  Hospital  Reports,  vol. 
xiv.,  1868. 

2  Wilson  Fox  :  "The  Diseases  of  the  Stomach,"  1872,  p.  146. 

^F.  Riegel :  Zeitschr.  f.  klin.  Med.,  Bd.  xii.,  p.  434,  and  Deutsche 
med.  Wochenschr.,  1886,  No.  52. 

^Jaworski  und  Korczynski :  Deutsche  med.  "Wochenschr.,  1886, 
Nos.  47-49. 

5  C.  A.  Ewald :  I.  c,  p.  229. 

« Charles  G.  Stockton:  "The  Etiology  of  Gastric  Ulcer."  TJie 
Medical  News,  January  14th,  1893. 


ULCER    OF    THE    STOMACH.  195 

rule,  and  twice  I  had  the  opportunity  of  observing  gas- 
tric ulcer  in  cases  in  which  there  was  an  entire  ab- 
sence of  gastric  juice  (achylia  gastrica).  One  of  these 
cases  did  not  present  any  symptoms  indicative  of  an 
ulcer,  the  latter  had  been  found  accidentally  in  per- 
forming an  exploratory  laparotomy  on  the  patient. 
This  case  is  as  follows : 

G.  M ,  56  years  old,  has  been  complaining  for 

the  last  three  years  of  attacks  of  dizziness,  extreme 
anorexia,  and  occasional  vomiting.  For  weeks  after 
such  an  attack  patient  could  not  walk  well  on  account 
of  a  giddy  feeling  which  he  often  experienced.  Bowels 
were  rather  constipated.  The  physical  examination 
of  the  patient  did  not  reveal  anything  abnormal,  ex- 
cept an  anaemic  state  which  found  expression  in  a  pale 
color  of  the  mucous  membrane  of  the  lips,  eyelids,  and 
the  palate.  A  splashing  sound  could  be  easily  pro- 
duced in  the  gastric  region  down  to  the  navel.  The 
urine  did  not  contain  sugar  or  albumin.  The  gastric 
contents  were  frequently  examined  in  the  course  of 
a  whole  year  with  always  about  the  same  result: 
HC1=0,  acidity  between  2  and  4,  no  rennet,  no  pep- 
sin, no  biuret  test.  Patient  improved  on  a  richly 
vegetable  diet  and  gained  some  pounds  in  weight. 
Suddenly,  however,  he  was  overcome  with  an  attack 
of  jaundice,  accompanied  with  severe  pains  and  fever. 
Since  that  time  the  pains  were  more  constant  than 
previously,  and  remained  so  even  after  the  jaundice 
had  entirely  disappeared.  The  patient's  condition 
turning  from  bad  to  worse,  a  consultation  was  held 
with  Drs.  A.  Eose  and  F.  Lange,  and  an  exploratory 
laparotomy  was  decided  upon,  gall-stones  apparently 
being  at  the  bottom  of  the  trouble.  The  operation 
was  performed  by  Dr.  F.  Lange  in  my  presence.     No 


196  DISEASES   OF   THE    STOMACH. 

gall-stones  were  found.  The  liver  appeared  normal. 
On  examining  the  stomach,  however,  a  small  spot 
(the  size  of  a  twenty -five-cent  piece),  situated  in  the 
anterior  wall  about  three  inches  distant  from  the 
lesser  curvature  as  well  as  from  the  pylorus,  was 
found  necrotized  and  on  the  border  of  perforation. 
This  piece  was  excised  and  a  typical  ulcer  found.  The 
stomach  was  sewn  together.  The  patient  got  along 
nicely  for  the  first  week  after  the  operation  when 
pneumonia  developed,  which  caused  a  fatal  issue. 

Ewald,  though  a  fervent  advocate  of  the  last  theory, 
presupposes  a  predisposition  of  certain  persons  to  this 
affection  in  order  to  explain  the  many  instances  where 
the  theory  of  hyperacidity  would  not  apply. 

The  probability  is  that  gastric  ulcer  is  not  always 
produced  by  one  and  the  same  factor,  and  all  the  above 
theories  may  apply  more  or  less  in  different  instances. 

Morbid  Anatomy. — The  peptic  ulcer  is  found  only 
in  those  regions  which  are  exposed  to  the  gastric 
juice.  Aside  from  the  stomach  it  is  met  with  in  the 
lowest  part  of  the  oesophagus  and  in  the  upper  part  of 
the  duodenum.  The  typical  gastric  ulcer  has  a  round 
or  oval  (sometimes  oblong)  appearance.  It  extends  to 
various  depths  of  the  gastric  wall,  the  upper  part 
being  the  larger,  the  inferior  smaller,  presenting  in 
this  way  more  or  less  the  shape  of  a  funnel. 

A  typical  ulcer  looks  as  if  it  were  cut  out  with  a 
punch.  In  most  instances  the  base  of  the  ulcer  is 
smooth,  occasionally  it  is  covered  with  tenacious 
greenish  or  brownish  mucus.  In  microscopic  sections 
through  the  margins  of  a  recent  ulcer,  the  ducts  of 
the  glands  appear  as  though  cut  off  toward  the  base 
of  the  ulcer.     They  are  eaten  away  or  digested  up  to 


ULCER   OF   THE    STOMACH, 


197 


the  point  wliere  the  tissues  offer  sufficient  resistance  to 
the  digestive  power  of  the  gastric  juice.  In  older 
ulcers,  however,  a  reactive  inflammation  sets  in  at  the 
periphery,  leading  to  the  formation  of  a  callous  mar- 


FlG.  39.— Ulcer  of  the  Stouuui 
a.  Stomach;  h.  iiylorus; 


I  .11  I  111-  I'yliuus,  tlie  latter  being  stenosed. 
nicer,     (From  writer's  observation.) 


gin.  The  latter  may  become  very  much  indurated, 
and  may  give  on  palpation  the  impression  of  a  tumor, 
the  more  so  if  the  thickened  portion  be  situated  near 
the  pylorus.  Aside  from  the  inflammation  of  the 
narrow  margin  of  the  ulcer,  the  mucous  membrane  of 
the  whole  stomach  remains  in  most  instances  normal, 
this  being  according  to  Eosenheim  '  a  principal  char- 
acteristic of  ulcer,  which  unlike  cancer  consists  in  a 

'  Th.  Rosenheim  :  "Pathologie  und  Tlierapie  der  Krankheiten  der 
Speiserohre  und  des  Magens, "  Wien  und  Leipzig,  1891,  p.  161. 


198 


DISEASES    OF   THE    STOMACH. 


well-circumscribed  necrotic  process  having  no  further 
influence  upon  the  gastric  mucosa. 

The  size  of  the  ulcer  is  rarely  much  smaller  than  a 


FiG.  40. — The  same  specimen  drawn  in  smaller  proportions,  in  order  to  show  the 
surroundings  of  the  ulcer. 


Fig.  41.— Showing  the  entire  cross-section  of  an  excised  ulcer  as  it  appears  under 
the  lens.  The  concave  line  forms  the  interior,  the  convex  the  outside  of  the 
stomach.  The  middle  portion  is  deprived  of  the  glandular  layer;  to  the  left  a 
few  glands  are  left.     X  4.     (From  writer's  observation.) 


ULCER    OF    THE    STOMACH.  199 

five-cent  piece  or  larger  than  a  twenty -five-cent  piece, 
although  no  j)recise  limits  can  be  given.  Thus  an 
ulcer  not  larger  than  a  pea  may  exhibit  all  the  charac- 
ters of  this  lesion,  while  conversely  an  ulcer  may  grad- 


.•;■■.■.-.. :  .•■.••..•:•••,■:.■;.■.-       ~ .        .,^     -   ■--«x--^. ■'■•!«*>?■•. 

.--:'^:5-^s.vv'.;:.iT-:;.i^K-  •■ ' .:....  vi?V^.;;:-^4?^ii»'^^ 

//.•'••v  v;--:'v-v- •f'^-•.=^•->^■■^<;■viv:>2•v■■J^         .  i-  -vv. '.■-.-.•■X'i  -.-Jr-  ••  *^'^^ 
■■^■•■■'.:•?>■•^^«'•i';^-iJ•t■■.'f^•  v>\>^^r--l^^^^  ,-".a'^'-"     '^ 

,4."  V'-'-r;iiS'.--'''V-.''.  v   ■  •■i;-"--"  ■"' 
Fig.  42.— The  left  comer  of  Fig.  41,  as  seen  under  the  microscope  with  low  power. 
Glands  are  visible  to  the  left  of  the  drawing,  the  rest  consisting  principally  of  a 
proliferation  of  cells  and  Connective-tissue  formation. 

ually  attain  a  diameter  of  five  or  six  inches.  Debove 
and  Remond '  mention  a  case  of  gastric  ulcer  of  the 
size  of  the  palm  of  the  hand. 

Situation   of  the    Ulcer. — According   to    Brinton/ 

'  Debove  etRemond  :  "Traice  des  Maladies  de  rEstomac, "  Paris, 
p.  255.  '^  W.  Rrinton  :  I.  c. 


200 


DISEASES    OF   THE    STOMACH. 


gastric  ulcer  occupies  the  various  parts  of  the  stomach 
in  the  followiDg  frequency:  In  43  cases  out  of  100 
the  posterior  surface,  in  27  cases  the  lesser  curvature, 
in  16  cases  the  pyloric  extremity,  in  6  cases  both  the 


Fig.  43. — Showing  One  Spot  of  a  Proliferation  of  Cells  lying  in  the  Centre  of  the 
Specimen  (Fig.  41 )  resembling  very  much  a  spindle-cell  sarcoma.  Highly  mag- 
nified. 

anterior    and   posterior   surfaces,    often    at    opposite 
places;  in  4  cases  the  anterior  surface  only,  in  2  cases 
its  greater  curvature,  in  2  cases  the  cardiac  pouch. 
Thus  about  86  ulcers  in  every  100  occupy  the  posterior 


ULCER   OF   THE    STOMACH.  201 

surface,  the  lesser  curvature,  the  pyloric  sac,  parts  of 
the  stomach  which  together  form  a  segment  of  less 
than  half  of  the  total  superficies  of  the  orgau. 

Hence  we  may  estimate  that  any  part  of  this  con- 
tinued (but  irregular)  segment  of  the  stomach  is  on 
an  average  about  five  times  more  liable  to  the  lesion 
than  the  remaining  segment  formed  by  the  cardiac 
sac,  the  anterior  surface,  and  the  greater  curvature. 

Nolte's'  figures  do  not  harmonize  with  those  just 
given.  Xolte  presents  the  following  scale  of  fre- 
quency: At  the  greater  curvature.  22:  at  the  py- 
lorus, 13:  at  the  anterior  wall,  o:  at  the  posterior 
wall.  2;  at  the  cardia,  1. 

Welch's  statistics  harmonize  more  with  Brintou's 
figures.  Out  of  793  cases  collected  by  this  eminent 
American  writer,  288  ulcers  were  situated  in  the  lesser 
curvature,  235  on  the  posterior  wall,  95  at  the  pylorus, 
96  at  the  anterior  wall,  50  at  the  cardia,  29  at  the 
fundus,  27  on  the  greater  curvature." 

Number. — As  regards  the  number  of  ulcers,  accord- 
ing to  Brinton,  2  or  more  are  present  in  1  out  of  every 
5  cases,  or  about  21  per  cent.  Out  of  97  such  plural 
cases  (corresponding  to  163  instances  of  ulcer),  in  57 
there  were  2  ulcers,  in  16.  3,  and  of  the  remaining  24 
in  which  "■  several"  ulcers  were  present.  3  cases  offered 
1  and  2  cases  5  ulcers  each :  while  in  4  there  is  reason 
to  suppose  even  this  number  was  exceeded. 

Further  Progress  of  the  Ulcer. — 1.  Cicatrization. 
The  ulcer,  as  a  rule,  does  not  heal  with  restitution  of 
the  normal  mucous  membrane,   but  leaves  behind  a 

I  Nolte  :  See  Ewald,  I.  c. ,  239. 

*  Welch:  Cited  from  Osier's  "Practice  of  Medicine,"  p.  369. 


202  DISEASES   OF   THE   STOMACH. 

fibrous,  centrally  depressed  scar,  which  has  a  tendeDcy 
to  contract.  If  such  a  scar  be  situated  at  the  pylorus, 
its  contraction  may  produce  stricture  of  this  outlet. 
If  the  ulcer  had  a  girdle-like  shape,  constriction  of  the 
viscus  may  occur,  and  give  it  the  form  of  an  hour- 
glass. 

2.  Progressive  Necrosis  and  Corrosion.  If  cica- 
trization does  not  occur,  the  necrotic  process  may  con- 
tinue for  a  long  period  and  may  cause  the  following 
complications: 

(a)  Corrosion  of  vessels.  Vessels  of  larger  or 
smaller  calibre  may  become  opened  and  give  rise  to 
hemorrhage,  or  if  a  very  large  vessel  is  affected  even 
to  fatal  bleeding.  Among  those  more  frequently 
involved  are  the  gastric,  splenic,  and  pancreatic 
arteries. 

(6)  Adhesions  to  neighboring  organs  and  perfora- 
tions. As  soon  as  necrosis  extends  to  the  serosa,  it 
leads  either  to  a  reactive  inflammation  with  adhesions 
to  surrounding  organs  and  extension  of  the  process  to 
them,  or  where  circumstances  do  not  permit  such  ad- 
hesions, to  a  direct  perforation  into  the  abdominal  cav- 
ity. After  the  adhesions  have  formed,  a  perforation 
may  yet  take  place  into  a  neighboring  cavity.  Thus 
perforation  into  the  pleural  or  pericardial  cavities  oc- 
curs, or  sometimes  a  fistula  is  formed  between  the 
stomach  and  duodenum  or  colon.  According  to  the 
site  of  the  ulcer,  any  of  the  neighboring  organs, 
liver,  gall  bladder,  pancreas,  spleen,  diaphragm, 
heart,  lungs,  etc.,  may  become  subject  to  these  ad- 
hesions. Perforations  of  the  anterior  wall  of  the 
stomach  are  most  dangerous  on  account  of  the  greater 


ULCER  OF  THE   STOMACH,  203 

mobility  of  this  part  of  the  organ  and  the  consequent 
lack  of  adhesive  inflammation.  These,  as  a  rule, 
terminate  fatally. 

Symptomatology . — ^A  typical  case  of  gastric  ulcer  is 
ushered  in  by  disturbances  of  the  gastric  digestion. 
At  the  beginning  there  is  merely  a  feeling  of  uneasi- 
ness and  pain  in  the  epigastric  region ;  but  these  are 
soon  followed  by  nausea  and  regurgitation  or  vomit- 
ing. These  symptoms  may  undergo  no  change  for  a 
long  period ;  at  times,  however,  they  become  more 
severe  in  character.  The  pains  especially  take  on  a 
more  aggravated  form,  and  many  patients  are  afraid 
to  eat  on  account  of  them.  Very  often  a  hemorrhage 
from  the  stomach  occurs,  producing  an  increase  of  the 
ansemia  and  cachexia  which  already  exist  in  conse- 
quence of  subnutrition.  If  the  disease  takes  a  pro- 
gressive course,  it  is  liable  to  end  lethally  by  perfora- 
tion, hemorrhage,  or  by  inanition.  In  most  instances, 
however,  the  course  of  the  disease  is  cut  short  either 
by  a  spontaneous  cicatrization  of  the  ulcer,  or  by  the 
same  process  being  brought  about  by  our  rational 
means  of  treatment.  The  symptoms  then  gradually 
disappear,  and  recovery  takes  place.  In  many  in- 
stances the  symptoms  of  the  disease  reappear  after  the 
lapse  of  various  periods  of  time  (one  or  several  years). 
It  is  then  quite  difficult  to  decide  whether  we  have  to 
deal  in  these  instances  with  the  formation  of  new 
ulcers,  or  a  breaking  down  of  the  cicatrix  of  the  old 
lesion.  As  the  above-mentioned  symptoms  of  ulcer 
are  met  with  likewise  in  many  other  disturbances  of 
the  stomach,  and  inasmuch  as  each  of  them  has  its 
specific  character  in  the  different  lesions,  it  will  be 


204  DISEASES  OF   THE   STOMACH. 

best  to  analyze  each  of  the  symptoms  of  gastric  ulcer 
separately. 

1.  Pain  is  the  most  frequent  and  characteristic  of 
all  the  symptoms.  In  the  earlier  stage 'of  the  disease 
there  is  a  mere  feeling  of  weight  or  tightness  in  the 
epigastric  region.  Sometimes  the  patient  has  the  im- 
pression as  though  the  food  experienced  a  stoppage 
there.  From  such  a  dull,  continuous  feeling  the  pain 
gradually  augments  into  a  burning  sensation  and  at 
last  into  a  gnawing  pain. 

In  the  majority  of  cases  the  pain  comes  on  from  two 
to  ten  minutes  after  deglutition  of  food  and  remains 
during  the  period  of  gastric  digestion,  at  the  close  of 
which  it  gradually  subsides  and  disappears.  There 
are,  however,  exceptions  to  this  rule,  and  we  find 
cases  of  typical  gastric  ulcer  where  the  pains  appear 
half  an  hour  or  an  hour  or  two  and  three  hours  after 
meals.  Different  kinds  of  food  have  a  marked  influ- 
ence upon  the  pain.  Coarse  substances  and  many 
undigestible  foods  increase  the  pain,  whereas  a  liquid 
diet,  especially  milk,  may  fail  to  bring  on  the  pain. 
The  quantity  of  food  is  also  of  import,  a  large  meal 
causing  more  pain  than  a  small  one. 

The  situation  of  the  pain  corresponds,  as  a  rule,  to 
the  centre  of  the  epigastrium,  or  to  the  median  line  of 
the  abdomen  immediately  below  the  free  extremity  of 
the  ensiform  process.  The  portion  of  the  epigastric 
region  to  which  the  pain  is  referred  forms  a  circular 
area  of  rarely  more  than  two  inches  diameter,  some- 
times a  mere  spot  of  less  than  half  this  size.  There 
are,  however,  exceptions  to  this  rule,  and  a  spot  of 
pain  may  be  situated  a  little  more  to  the  right  or  to 


ULCER   OF   THE   STOMACH.  205 

the  left  or  also  farther  down  than  the  above-described 
spot.  Occasionally  the  pain  is  associated  with  a  feel- 
ing of  violent  pulsation  or  throbbing  in  the  epigastric 
region.  At  times  this  sensation  is  felt  independently 
of  the  paroxysm  of  pain. 

The  dorsal  pain,  first  described  by  Cruveilhier,  is 
also  an  important  symptom.  It  generally  appears 
later  (a  few  weeks  or  montbs)  than  the  epigastric 
pain,  and  is  then  almost  as  constant  and  characteristic 
as  the  epigastric  pain.  This  pain  is  gnawing  in  char- 
acter and  situated,  as  a  rule,  to  the  left  of  the  spine 
corresponding  to  the  eighth  or  ninth  dorsal  vertebra, 
and  extending  occasionally  to  that  of  the  first  or 
second  lumbar  vertebra.  Like  the  eiDigastric  pain,  it 
has  a  fixed  seat,  generally  remaining  near  the  spot  of 
its  first  appearance  during  the  whole  progress  of  the 
disease,  although  it  also  shows  lateral  as  well  as  verti- 
cal deviation  from  its  ordinary  situation.  Its  worst 
attacks  generally  alternate  with  those  of  the  epigastric 
pain. 

The  epigastric  pain  is  increased  on  pressure.  Even 
slight  pressure  with  the  finger  upon  the  epigastric  re- 
gion below  the  ensiform  process  produces  intense  pain. 
This  is  the  most  important  point  characteristic  of  gas- 
tric ulcer.  To  test  the  sensitiveness  to  jDressure  by 
means  of  Boas'  algesimeter.  or  to  exert  considerable 
pressure  with  the  fingers,  is  not  advisable.  I  perfect- 
ly agree  with  Brinton,'  who  says  in  reference  to  the 
latter  point :  "It  is  not  altogether  superfluous  to  add 
another  caution  with  respect  to  the  above  test  (pres- 
sure) :  not  only  must  it  be  applied  w'ith  great  care  and 

'  W.  Brinton  :  I  c. 


206  DISEASES   OF   THE   STOMACH. 

delicacy  in  the  first  examination  of  a  supposed  case  of 
gastric  nicer,  but,  as  a  rule,  we  can  scarcely  be  too  re- 
luctant to  repeat  it,  even  to  verify  a  presumed  amend- 
ment. At  any  rate,  its  effects  are  sometimes  so 
injurious  that  it  is  necessary  strictly  to  prohibit  the 
patient  from  all  manipulations  of  the  epigastric  re- 
gion, as  well  as  from  all  pressure  produced  b}'  dress 
(such  as  stays  in  the  female)  or  work  (as  is  the  case 
with  shoemakers)." 

The  character  of  the  pain,  of  becoming  increased  on 
pressure,  is,  however,  not  always  present,  and  we  find 
patients  with  gastric  ulcer  in  whom  the  pain  is  rather 
subdued  by  pressure. 

2.  Vomiting.  Vomiting  in  gastric  ulcer  occurs  in 
nearly  the  same  proportion  of  cases  as  pain.  As  a 
rule,  it  is  absent  during  the  first  period  of  the  disease, 
and  appears  somewhat  later  than  the  pain.  Some- 
times, however,  both  these  symptoms  occur  simulta- 
neously. The  vomiting,  most  frequently  met  with  in 
cases  of  ulcer,  appears  an  hour  or  two  after  meals,  at 
the  time  when  the  pain  has  reached  its  acme.  As  a 
rule,  the  vomiting  relieves  the  pain.  Sometimes  the 
vomiting  occurs  less  frequently,  for  instance  once  a 
day  or  still  more  seldom.  The  vomited  matter  ordi- 
narily consists  of  a  water}'  fluid  mixed  with  particles 
of  food.  Occasionally,  however,  the  latter  are  absent 
and  the  ejected  matter  then  consists,  as  a  rule,  of 
clear  gastric  juice  which,  in  many  cases  of  ulcer,  is 
secreted  in  too  abundant  a  quantity.  In  such  in- 
stances the  vomiting  may  occur  independently  of  the 
meals,  and  thus  may  take  place  either  in  the  middle  of 
the  night  or  early  in  the  morning  on  arising. 


ULCER   OF   THE   STOMACH.  207 

There  are  also  cases  in  which  vomiting  takes  place 
very  soon  after  meals,  or  where,  instead  of  the  vomit- 
ing, there  is  regurgitation  of  food.  The  regurgitation 
may  also  occur  two  to  three  hours  after  a  meal  (the 
fluid  brought  up  consisting  of  very  acid  gastric  chyme 
or  juice)  and  is  very  often  accompanied  hy  pyrosis. 
Again  there  are  cases  in  which  instead  of  the  vomiting 
we  have  spells  of  nausea.  Vomiting  of  very  large 
quantities  of  chyme,  although  met  with  in  gastric 
ulcer,  is  most  characteristic  of  cases  of  ulcer  compli- 
cated with  stenosis  of  the  pylorus,  and  will  be  dis- 
cussed later  on  when  dealing  with  that  affection. 

3.  Hemorrhage.  Hemorrhage  is  a  symptom  of  the 
greatest  importance  in  gastric  ulcer.  Since  the  proc- 
ess of  ulceration  implies  a  solution  of  continuity  in 
the  coats  of  the  vessels  of  the  stomach,  there  is  noth- 
ing more  natural  than  an  effusion  of  blood.  As  a 
rule,  however,  the  opening  of  the  vessels  is  very  soon 
obliterated  by  the  formation  of  a  coagulum.  For  this 
reason  hemorrhages  occurring  from  the  very  small 
vessels  are  not  of  much  import,  and  pass  unnoticed  by 
the  physician  or  the  patient.  It  is  only  when  a  larger 
vessel  is  corroded  and  a  considerable  quantity  of  blood 
enters  the  stomach  that  grave  symptoms  appear.  In 
a  typical  case  of  such  a  hemorrhage  the  patient  ex- 
periences a  sensation  of  fulness  soon  after  a  meal, 
combined  with  aiixiety.  Some  time  afterward  he 
feels  nauseous,  restless.  Suddenly  vomiting  of  a 
large  quantity  of  blood  occurs,  having  either  a  clear 
red,  brownish,  or  black  color,  possibly  mixed  with  food 
(hsematemesis).  The  patient,  as  a  rule,  feels  faint,  his 
face  becomes  pale,  his  extremities  grow  more  or  less 


208  DISEASES   OF   THE   STOMACH. 

cold,  and  if  the  hemorrhage  goes  on  uninterruptedly, 
death  is  likely  to  occur  in  consequence  of  the  profuse 
loss  of  blood.  Under  such  circumstances  the  patient 
soon  becomes  unconscious,  convulsions  supervene,  and 
life  is  gradually  extinguished.  If  hemorrhage  of  a 
large  vessel  has  taken  place,  it  may  even  happen  tliat 
the  patient  dies  before  any  vomiting  has  occurred.  In 
such  instances  the  cause  of  death,  if  there  have  been 
no  previous  symptoms  of  ulcer,  usually  remains  un- 
known until  the  autopsy,  when  the  stomach  may  be 
found  filled  with  liquid  or  coagulated  blood.  In  most 
cases,  however,  gastric  hemorrhage  is  not  lethal. 
The  blood,  instead  of  being  vomited,  may  pass  into  the 
intestines,  and  be  evacuated  with  the  stools,  which 
then  assume  a  blackish,  tarry  color  (melsena).  Very 
often  both  hsematemesis  and  melsena  take  place. 

Blood  vomiting  (hsematemesis),  if  present,  is  the 
most  certain  sign  of  ulcer,  and  its  occurrence  alone  is 
sufficient  to  warrant  a  positive  diagnosis  of  this  affec- 
tion. In  almost  one-third  of  his  cases  of  ulcer,  Ander- 
son '  found  this  symptom  present.  There  is  no  doubt 
that  hemorrhages  in  gastric  ulcer  appear  more  fre- 
quently than  we  are  able  to  recognize  their  existence. 
Very  often  in  small  hemorrhages  the  blood  will  pass 
through  the  digestive  canal  unnoticed,  the  reason 
being  that  small  quantities  of  blood  mixed  with  ali- 
mentary residues  may  be  changed  in  such  a  way  as 
to  be  unrecognizable.  Even  if  blood  be  present  in  the 
stools  in  larger  amounts,  it  will  sometimes  pass  un- 
noticed because  the  patient  does  not  pay  attention  to 
their  color,  especially  nowadays  when  every  one  goes 

'Anderson:  British  MedicalJonrnal,  May  10th.  1890. 


ULCER   OF   THE   STOMACH.  209 

to  the  water-closet,  and  is  not  in  the  habit  of  inspect- 
ing his  passages.  Not  long  ago  I  had  the  opportunity 
twice  of  detecting  blood  in  the  stomach  of  patients 
who  apparently  never  had  any  hemorrhages.  In  one 
of  them,  at  the  examination  with  the  tube  one  hour 
after  the  test  breakfast,  I  obtained  quite  a  quantity  of 
blood  having  a  black  coffee-ground  color  (under  the 
microscope  red  blood  corpuscles  were  present).  The 
second  patient  was  a  lady  presenting  symptoms  of 
gastric  ulcer.  While  in  the  clinic,  I  noticed  that  she 
looked  unusually  pale ;  she  also  complained  of  feeling 
somewhat  faint.  As  she  had  partaken  of  a  test  break- 
fast, I  administered  the  stomach  bucket,  which  came 
up  filled  with  a  fluid  of  coffee-ground  color,  also  con- 
taining red  blood  corpuscles. 

4.  Appetite.  Although  patients  with  gastric  ulcer 
partake  of  very  small  quantities  of  food,  the  appetite 
per  se  is  by  no  means  decreased.  It  is  merely  on  ac- 
count of  the  pains  that  the  patients  are  afraid  to  eat, 
and  avoid  substantial  meals.  Some  complain  of  being 
constantly  hungry,  but  unable  to  satisfy  their  appe- 
tite, on  account  of  the  distress  following  the  ingestion 
of  food.  This  fear  of  taking  food  is  sometimes  exag- 
gerated, and  the  patients  get  into  a  habit  of  partaking 
of  so  little  that  the  danger  resulting  from  this  source 
is  certainly  far  greater  than  that  from  the  original 
disease. 

5.  Constipation.  As  a  rule,  most  cases  of  gastric 
ulcer  are  accompanied  by  constipation.  Leube'  ex- 
plains this  fact  in  the  following  manner:  He  assumes 
that  the  peristalsis  of  the  stomach  is  impaired  in  gas- 

14  1  Leube  :  I.  c. 


210  DISEASES   OF   THE   STOMACH. 

trie  ulcer.  As  there  is  a  reflex  connection  between  the 
peristalsis  of  the  stomach  and  that  of  the  small  intes- 
tines, the  latter  will  also  be  retarded,  and  in  this  way 
the  constipation  would  be  explained.  Leube's  theory 
of  the  presence  of  retarded  muscular  action  in  gastric 
ulcer  seems  to  be  suj^ported  by  several  results  wdiich 
I  have  obtained  with  the  gastrograph  in  a  few  cases 
of  gastric  ulcer,  in  which  the  motion  of  the  stomach 
appeared  to  be  materially  lessened,  M3"  observations 
in  this  respect,  however,  are  yet  too  few  to  fully  sus- 
tain this  theory. 

6.  Amenorrhoea.  Amenorrhoea  is  quite  frequently 
met  with  in  women  suffering  from  gastric  ulcer.  It 
appears,  however,  that  this  symptom  is  merely  the 
consequence  of  the  ansemic  condition  of  these  patients. 
Sometimes  gastric  hemorrhages  vicariously  appear 
instead  of  the  monthly  periods. 

7.  Cachexia.  Although  we  sometimes  meet  with 
robust,  healthy  persons  suffering  from  gastric  ulcer, 
this  is  not  the  rule,  and  most  frequently  patients 
suffering  from  this  trouble  present  an  appearance 
which  would  suggest  to  an  observant  physician  even 
at  a  distance  the  nature  of  the  ailment.  In  connec- 
tion with  the  extreme  cachexia,  the  sharp  lines  which 
severe  and  frequent  pains,  together  with  partial  starva- 
tion, have  graven  on  the  patient's  face  afford  almost 
a  characteristic  sign  of  gastric  ulcer.  The  cachexia 
in  gastric  ulcer,  although  at  first  not  well  marked, 
may  after  a  time  increase  to  such  an  extent  that  the 
patient  is  reduced  to  a  mere  skeleton,  and  emaciation 
of  this  kind  is  very  seldom  met  wnth  in  gastric  cancer. 

Condition  of  the   Gastric   Contents. — Eiegel,    and 


ULCER   OF   THE   STOMACH.  -211 

later  Jaworski  and  Glusinsky,  first  signalized  the  fact 
that  hyperacidity  is  a  coucomitant  factor  of  gastric 
ulcer.  Although  this  is  uot  always  the  case,  as  we 
have  mentioned  above,  the  fact  remains  true  that 
most  of  the  cases  of  gastric  nicer  are  characterized  by 
an  hyperacid  juice.  The  acidity  may  reach  as  high  a 
figure  as  130  or  even  160  (about  three  or  four  times 
the  acidity  of  normal  gastric  juice).  This  high  figure, 
160,  I  had  the  opportunity  to  observe  lately  in  a  case 
of  gastric  ulcer  near  the  pylorus  combined  with  ste- 
nosis of  the  latter.  The  patient  had  been  operated 
upon,  and  the  diagnosis  verified  in  vivo  in  this  man- 
ner. In  cases  in  which  there  is  vomiting  the  ejected 
matter  should  be  examined.  If  vomiting  is  absent 
the  gastric  contents  may  be  obtained  for  examination 
with  the  stomach  bucket.  The  examination  of  the 
gastric  contents  by  means  of  any  instrument  should 
be  performed  with  the  greatest  caution,  and  only  in 
those  instances  where  the  diagnosis  of  gastric  ulcer  is 
doubtful.  Whenever  there  are  sufficient  symptoms 
to  make  the  diagnosis  pretty  certain,  the  employment 
of  an  instrument  should  be  omitted.  Most  writers 
are  opposed  to  the  application  of  the  tube  in  gastric 
ulcer. 

Latent  Ulcer. — All  the  above  symptoms  of  gastric 
ulcer  may  at  times  be  missing,  and  the  sickness  may 
remain  concealed.  It  is  well  known  that  scars  result- 
ing from  ulcer  are  found  at  autopsies  in  the  stomachs 
of  people  who  apparently  never  had  any  gastric 
trouble. 

The  following  is  a  good  example  of  an  ulcer  without 
typical   subjective   symptoms,   showing   at  the   same 


212  DISEASES   OP   THE   STOMACH. 

time  the  importance  of  hemorrhage  as  a  diagnostic 
sign : 

Mrs.  H ,  44  5"ears  old,  has  been  complaining  for 

the  last  five  years  of  frequent  belching,  poor  appetite, 
and  constant  pains  of  a  very  slight  character  in  the  epi- 
gastric region.  Patient  never  had  any  hemorrhage  nor 
any  intense  pains,  and  her  bowels  were  always  regu- 
lar. During  her  illness  she  has  lost  eight  pounds,  and 
looks  extremely  pale  and  ansemic.  The  examination 
of  the  abdomen  reveals  the  position  of  the  stomach  be- 
tween the  navel  and  one  finger's  width  above  the  pubes. 
There  is  no  pain  on  pressure  either  in  the  epigastric  or 
gastric  region,  although  the  epigastrium  is  somewhat 
sensitive  to  pressure.  Eight  kidney  movable.  Ex- 
amination with  the  tube  one  hour  after  the  test 
breakfast  results  in  the  withdrawal  of  coffee-colored 
contents  mixed  with  fine  particles  of  bread ;  the  mi- 
croscope shows  numerous  red  blood  corpuscles;  the 
chemical  analysis  of  the  filtrate  reveals  HCl-f-acidity 
=  76.  On  the  next  day  the  patient's  stools  were  black 
from  admixture  with  blood. 

The  diagnosis  of  gastric  ulcer  was  made  and  the 
patient  treated  accordingly.  She  gradually  recuper- 
ated, and  under  a  further  tonic  treatment  entirely  re- 
covered, and  has  remained  free  from  any  symptoms 
for  the  last  two  years. 

Again,  such  a  latent  ulcer  may  sometimes  suddenly 
give  rise  to  alarming  symptoms,  and  even  cause  death 
from  perforation  or  a  profused  hemorrhage. 

Duration  of  the  Disease. — The  duration  of  gastric 
ulcer  is  sometimes  extremely  long.  Brinton  cites 
cases  in  which  the  sickness  had  lasted  from  thirty  to 
thirty-five  years. 


ULCER    OF   THE   STOMACH.  213 

Complications. — Complications  quite  frequently 
appear  during  the  protracted  course  of  this  affection. 
These  may  comprise  a  sudden  exacerbation  of  one  of 
the  usual  symptoms,  as  for  instance  the  jDain  or  vomit- 
ing, which  may  become  uncontrollable,  and  hemor- 
rhage, which  may  become  fatal  in  a  few  hours  or 
even  in  a  few  minutes.  Again,  they  are  sometimes 
caused  by  intercurrent  phenomena. 

Perforation. — The  most  dangerous  complication  of 
gastric  ulcer  is  perforation,  which  is  due  to  an  exten- 
sion of  the  ulcerative  process  through  the  whole  stom- 
ach wall  to  the  peritoneum.  It  is  followed  by  slough- 
ing or  rupture  of  these  delicate  membranes,  and  by 
the  effusion  of  the  contents  of  the  stomach  into  the 
peritoneal  cavity.  The  perforation  is  accompanied  by 
very  intense  and  characteristic  symptoms.  The  pa- 
tient is  suddenly  attacked  by  a  violent  pain,  which 
begins  in  the  epigastric  region,  and  rapidly  spreads 
over  the  abdomen.  Sometimes  the  patients  have  a 
sensation  as  if  something  had  given  way  in  their  ab- 
dominal cavity,  and  a  gush  of  liquid  had  occurred. 
Symptoms  of  general  peritonitis  now  quickly  appear. 
In  a  short  time  the  whole  abdomen  becomes  greatly 
distended  and  extremely  painful  to  the  slightest 
touch.  Entrance  of  gas  into  the  abdominal  cavity  oc- 
curs, in  consequence  of  which  the  dulness  of  the  liver 
sometimes  disappears ;  at  times,  again,  emphysema  of 
the  skin  develops.  The  extremities  become  cold,  while 
the  temperature  of  the  body  rises.  The  pulse  becomes 
very  small  and  can  hardly  be  counted.  A  cold  sweat 
breaks  out  on  the  face,  which  wears  an  expression  of 
extreme   anxiety    (facies  Hippocratica) ;    singultus  is 


214  DISEASES   OF   THE   STOMACH. 

present,  as  a  rule,  while  vomiting  may  at  times  be 
absent  (in  those  instances  where  the  entire  contents  of 
the  stomach  have  escajDed  into  the  abdominal  cavity). 
After  a  short  period  of  coma  the  patient  usually  dies. 
Rarely  does  the  train  of  symptoms  following  perfo- 
ration offer  a  marked  deviation  from  the  above  descrip- 
tion. In  many  instances,  a  remarkable  paroxysm  of 
pain  precedes  the  occurrence  of  perforation.  This 
pain,  the  duration  of  which  varies  from  a  few  minutes 
to  several  hours,  is  generally  due  to  a  leakage  of  the 
gastric  contents  through  the  thin  film  of  rotten  tissue, 
to  which  at  this  period  the  coats  of  the  stomach  are 
reduced.  Partial  perforation,  allowing  of  a  subsequent 
repetition  of  the  accident,  or  leading  to  abscess,  pre- 
sents symptoms  of  a  more  local,  more  chronic,  and  less 
intense  character  than  those  of  ordinary  perforation. 
Perforation  nearly  always  occurs  after  a  full  meal, 
and  is  often  traceable  to  mechanical  violence,  such  as 
coughing,  sneezing,  or  constriction  of  the  abdomen. 

Sometimes,  before  the  perforation  arises,  an  adhesive 
inflammatory  process  takes  place,  in  consequence  of 
which  the  stomach  in  the  affected  area  becomes  ad- 
herent to  neighboring  organs,  a  process  which  may 
then  prevent  the  entrance  of  the  gastric  contents  into 
the  peritoneal  cavity.  A  local  abscess  is  very  often 
the  result  of  such  an  occurrence.  This  form  of  ab- 
scess may  open  into  different  cavities;  thus,  for  in- 
stance, a  fistulous  opening  between  the  stomach  and 
the  colon,  or  the  stomach  and  the  abdomen,  has  fre- 
quently been  found  established.  Again,  the  abscess 
may  perforate  the  diaphragm  and  lung,  and  be  evacu- 
ated in  this  way.     As  these  instances  are  not  so  very 


ULCER   OF   THE   STOMACH.  215 

frequent,  I  will  here  mention  a  case  of  this  kind  which 
I  observed  ten  years  ago. 

A  lady,  about  30  years  old,  after  a  short  period 
of  slight  dyspeptic  symptoms,  was  suddenly  attacked 
with  profuse  gastric  hemorrhages.  On  the  first  day 
she  vomited  about  one  pint  and  a  half  of  almost  clear 
blood,  the  vomiting  being  accompanied  by  severe  pains 
in  the  gastric  region.  She  was  kept  in  bed,  an  ice-bag 
applied  to  her  abdomen,  and  large  doses  of  opiates  were 
administered.  On  the  following  day  the  hsemateme- 
sis  was  repeated.  Under  the  above  treatment,  how- 
ever, the  patient  began  slightly  to  improve  and  to  take 
small  quantities  of  milk.  About  a  week  after  the  first 
hemorrhage  she  suddenly  experienced  a  more  intense 
pain  in  her  abdomen,  followed  by  all  the  symptoms  of 
severe  collapse.  Singultus  appeared,  the  abdomen 
swelled,  and  became  extremely  painful  to  the  touch, 
while  the  temperature  rose  to  104°,  the  pulse  to  140, 
and  the  extremities  grew  cold.  The  diagnosis  of  per- 
foration of  the  ulcer  was  quite  clear,  and  the  patient 
was  believed  to  be  dying.  This  critical  state  re- 
mained unchanged  for  about  four  or  five  days,  when 
suddenly  the  dyspnoea,  which  had  before  existed  in  a 
slight  degree,  increased,  while  the  expired  air  assumed 
a  very  offensive  odor.  This  symjDtom  increased  to 
such  a  degree  that  it  was  hardly  possible  to  sit  in  the 
same  room  with  the  patient.  About  two  days  later, 
during  which  period  the  offensive  smell  constantly 
persisted  with  undiminished  strength,  the  patient 
brought  up  during  several  spasmodic  coughing-spells 
about  one  pint  and  a  half  of  pus,  in  which  particles  of 
casein  and  small  black  flakes  could  be  clearly  seen. 
This  matter  had  exactly  the  same  odor  as  the  air  ex- 
pired by  the  patient  for  the  last  two  days.  Immedi- 
ately after  this  occurrence   the  expired   air  entirely 


210  DISEASES   OF   THE   STOMACH. 

changed  its  character,  and  the  atmosphere  of  the  room 
was  no  longer  unpleasant ;  the  patient  began  to  feel 
better,  the  temperature  fell,  all  the  symptoms  of  peri- 
tonitis began  to  disappear,  and  she  made  a  slow  re- 
covery in  about  six  weeks.  In  this  case  after  the  per- 
foration of  the  stomach  there  must  have  formed  a 
localized  abscess,  which  extended  through  the  dia- 
phragm into  the  lung  and  emptied  itself  through  a 
bronchus. 

By  a  similar  process  an  abscess  may  form  beneath 
the  diaphragm,  and  may  at  times  cause  a  condition 
which  Leyden  '  designated  as  '"  PyoiDueumothorax  sub- 
j)hrenicus^^  on  account  of  its  similarity  to  the  real  pyo- 
pneumothorax. This  condition  appears  only  when  gas 
is  contained  in  the  abscess.  Debove  and  Eemond ' 
designate  it  by  the  more  correct  term  "gaseous  subdia- 
phragmatic abscess,"  while  in  this  country  it  is  briefly 
called  "subphrenic  abscess."  The  abscess  is,  as  a 
rule,  situated  toward  the  right  side.  Its  walls  are 
formed  by  the  diajDhragm  above,  by  the  liver  and  the 
stomach  below ;  to  the  right  it  is  surrounded  by  the 
suspensory  ligaments  of  the  liver,  and  to  the  left  by 
the  spleen.  The  liver  is  usually  pushed  downward 
and  the  diaphragm  upward.  Thick  false  membranes 
form  the  walls  of  the  abscess,  which  contains  gas  and 
fetid  liquids,  the  latter  being  composed  of  pus  and 
alimentary  residues. 

The  symptoms  that  are  caused  by  this  condition  are: 
the  respiratory  vibrations  of  the  lower  part  of  the 
thorax  disappear;  the  liver  dulness  in  the  back  and 

'  E.   Le.yden  :    "Ueber  Pyopneumothorax  subphrenicus  iind  siib- 
phrenische  Abscesse. "     Zeitschr.  f.  klin.  Med.,  1880,  p.  320. 
'^  Debove  et  Remoud  :  I.  c,  p.  272. 


ULCER   OF  THE   STOMACH.  217 

the  lower  part  of  the  luug  are  replaced  by  a  zone  giv- 
ing a  tympanitic  sound  on  percussion.  On  auscultation 
the  resjDiratory  sounds  are  not  audible,  but  there  are 
heard  instead  succussion  sounds  of  a  metallic  pitch. 
The  best  diagnostic  sign  of  this  condition  is  afforded 
by  exploratory  puncture,  by  means  of  which  one  can 
aspirate  pus  containing  some  food  particles.  Another 
diagnostic  point  of  value  has  been  suggested  by  Pfuhl,' 
and  consists  in  connecting  the  exploratory  needle  with 
a  manometer.  The  pressure  in  this  affection  is 
greater  during  inspiration  and  less  during  expiration, 
whereas  in  real  pyopneumothorax  this  condition  of 
pressure  will  be  found  reversed.  Of  late  this  disease 
has  been  recognized  during  life  and  successfully  oper- 
ated upon  by  incision  of  the  abscess  and  cleansing  of 
the  cavity.  C.  Beck,'  of  Xew  York,  has  recently  re- 
ported three  successfully  operated  cases  of  subphrenic 
abscess. 

The  local  abscess  caused  by  perforation  can  also  at 
times  produce  other  complications ;  thus,  for  instance, 
it  may  perforate  the  abdominal  wall,  with  establish- 
ment of  a  fistulous  opening  from  the  stomach  to  the 
outside.  Although  very  rare,  cases  are  also  mentioned 
in  which  an  abscess  of  the  stomach  has  perforated 
the  pericardium,  and  even  the  heart  itself,  causing 
death. 

As  regards  the  frequency  of  perforation  in  the 
course  of  gastric  ulcer,  it  occurs,  according  to  Brinton, 
in  not  more  than  one  out  of  seven  or  eight  cases  of 
this  lesion ;  while  sex  has  no  influence  upon  the  fre- 

iPfuhl:  Berliner  klin.  Wochenschrift,  1877,  p.  57. 
-  C.  Beck  :  Medical  Eecord,  February  loth,  1896. 


218  DISEASES   OF   THE  STOMACH. 

quency  of  its  occurrence,  the  age  of  the  patient  seems 
to  play  an  important  joart  in  tiiis  respect. 

Although  gastric  ulcer  is  met  with  more  frequently 
as  life  advances,  the  occurrence  of  perforation,  on  the 
contrary,  declines  from  the  age  of  30  to  that  of  TO. 
According  to  Brinton,  the  distribution  of  the  liability 
to  perforation  over  the  whole  life  varies  materially  in 
the  two  sexes.  In  the  female  about  one-half  of  the 
number  of  cases  occur  between  the  ages  of  14  and  30, 
one-third  in  the  six  years  between  14  and  20.  In  the 
male  the  distribution  is  constant  up  to  the  age  of  50, 
and  diminishes  but  little  up  to  that  of  TO.  The  aver- 
age age  of  those  subject  to  perforation  also  differs  in 
the  two  sexes,  being  21  in  the  female,  42  in  the  male. 
The  situation  of  the  perforating  ulcer  plays  the  chief 
part  in  the  frequency  of  this  occurrence.  The  anterior 
surface  of  the  stomach,  though  much  more  rarely 
affected  by  ulcer,  is  yet  one  of  the  most  frequent  sites 
of  perforation.  According  to  Brinton,  in  all  other 
situations  of  the  ulcer,  the  probabilities  are  about  60 
to  1  against  perforation,  while  in  the  anterior  surface 
of  the  stomach,  they  are  G  to  1  in  its  favor.  The 
reason  for  this  is  the  circumstance  that  the  front  wall 
of  the  stomach  is  more  exposed  to  motion  than  all 
other  parts  of  the  stomach  where  ulcer  is  usually 
found.  The  mobility  of  this  part  prevents  the  forma- 
tion of  adhesions,  which  often  form  if  the  ulcer  is 
situated  elsewhere. 

The  gastric  ulcer  is  liable  to  bring  in  its  train  still 
other  complications :  thus  in  some  instances  a  cancer 
may  be  developed  on  the  base  of  an  ulcer  or  on  its 
scar.     Dittricli  was  the  first  to  describe  this  compli- 


ULCER  OF   THE   STOMACH.  219 

catioD,  and  Eosenheim '  has  lately  published  several 
important  investigations  on  this  subject.  The  same 
writer  ^  has  also  described  another  complication  of 
chronic  gastric  ulcer,  and  that  is  a  grave  form  of 
ansemia,  which  may  be  styled  "pernicious." 

Pulmonary  tuberculosis  is  a  frequent  occurrence  in 
gastric  ulcer,  as  in  many  other  chronic  diseases,  and 
hastens  the  death  of  the  patient.  It  does  not  seem, 
however,  that  there  is  a  more  intimate  connection 
between  these  tw^o  affections  than  obtains  in  other 
diseases. 

As  mentioned  above  in  speaking  of  the  pathology  of 
the  ulcer,  severe  complications  may  arise  from  the 
thickening  of  a  cicatrix,  especially  if  situated  at  the 
pylorus,  or  very  near  it,  or  again  at  the  cardia.  In 
the  first  instance,  the  most  frequent  complication  is 
stenosis  of  the  pylorus  with  dilatation  of  the  stomach, 
which  will  be  treated  in  a  special  chapter  under  Ischo- 
chymia;  in  the  second,  stricture  of  the  cardia,  caus- 
ing dysphagia. 

Diagnosis. — In  cases  where  all  the  symptoms  of 
gastric  ulcer  are  present  no  difficulty  will  be  experi- 
enced in  the  diagnosis.  It  frequently  happens,  how- 
ever, that  only  one  or  two  of  the  above-described 
symptoms  exist,  and  it  is  then  more  difficult  to  make 
a  positive  diagnosis.  One  of  the  following  symptoms, 
if  present  in  its  characteristic  form,  will  suffice  to 
establish  a  probable  diagnosis  of  ulcer. 

1.   Hgematemesis.     If  the  quantity  of  blood  vomited 

'Th.    Rosenheim:    "Zur  Kenntniss  des  mit  Krebs  coraplicirten 
runden  Magengeschwiirs. "    Zeitschr.  f.  klin.  Med.,  Bd.  17,  p.  116. 
-  Th.  Rosenheim:  Deutsche  med.  Wochenschr. ,  1890,  No.  15 


220  DISEASES   OF   THE   STOMACH. 

be  quite   large,   and   cancer   of  the  stomach  can   be 
excluded. 

2.  Pains.  Pains  appearing  shortly  after  meals,  and 
lasting  for  a  considerable  time  (two  to  three  hours), 
being  influenced  by  the  quantity  and  quality  of  food 
in  such  a  way  that  the}^  are  most  intense  after  the 
ingestion  of  coarse  substances  in  large  quantities, 
without  perfectly  free  intervals  of  several  days'  dura- 
tion, are  sufficient  to  warrant  the  suspicion  of  gastric 
ulcer.  If  in  connection  with  this  spontaneous  pain 
there  is  a  circumscribed  spot  in  the  epigastric  region 
that  is  painful  to  pressure,  or  if  there  is  a  small  area 
likewise  painful  to  pressure  to  the  left  of  the  eighth 
or  ninth  dorsal  vertebra,  then  the  diagnosis  of  an  ulcer 
becomes  probable. 

3.  Vomiting.  Vomiting  aj)pearing  shortly  after 
meals  and  preceded  by  a  period  of  uneasiness  in  the 
gastric  region,  may  also  at  times  be  suspicious  of  gas- 
tric ulcer.  If  this  occurs  in  individuals  who  have 
lately  grown  much  paler  and  more  anaemic,  the  sus- 
picion again  becomes  a  probability.  This  probability 
is  still  greater  if  the  gastric  contents  show  a  too  high 
degree  of  acidity. 

Differential  Diagnosis. — Very  often  cases  of  pure 
nervous  gastralgia,  of  hyperchlorhydria,  and  of  cancer 
present  symptoms  similar  to  those  of  gastric  ulcer, 
and  in  making  the  diagnosis  we  shall  have  to  take  all 
these  affections  into  consideration.  Following  Ewald's 
example,  I  deem  it  best  to  give  all  points  of  differen- 
tial diagnosis  between  the  above-named  conditions  in 
a  table: 


ULCER   OF   THE   STOMACH. 


321 


Age. 


Sex., 


Epigastric 
pain. 


Appetite . 


Tougue . . 


Taste 

Belching . 


Regurgita- 
tion. 


Vomiting. . 


Hsemate- 
mesis. 


Gastric  ulcer. 


Rare  in  youth, 
frequency  increas- 
i  n  g  progressively 
from  puberty  to  a 
very  advanced  age. 

More  frequent  in 
women  (2  : 1). 

Quite  intense;  ap- 
pears shortly  after 
meals;  grovs^s  s  e  - 
verer  on  pressure; 
disappears  at  the 
end  of  the  digestive 
period;  seldom 
perfectly  free  pe- 
riods. 


Appetite  not  impair- 
ed, although  p  a  - 
tient  as  a  rule  eats 
less  on  account  of 
his  suffering. 

Dry  and  red,  show- 
ing a  white  stripe 
in  the  middle,  or 
smooth  and  moist 
or  slightly  furred. 

Nothing  abnormal. . . 

As  a  rule  absent;  If 
present,  without 
any  bad  odor. 


At  times  present, 
frequently  water 
brash  associated 
with  pyrosis. 

Appears  in  some 
cases  soon  after 
meals. 


Vomiting  of  a  large 
quantity  of  blood, 
either  clear  red  or 
o  f  coffee  -  ground 
color.  Blood  is  also 
found  in  the  stools. 
A  repetition  of  the 
hffimatemesis  may 
occur  on  the  fol- 
lowing day,  but  if 
once  arrested  it 
does  not  reappear 
for  quite  a  long 
period. 


Nervous 
gastralgia. 


Most  frequent 
between  the 
ages  of  18  to 
35. 


More  frequent 
in  women. 

The  pain  ap- 
pears wi  th  - 
out  regular- 
ity and  is  not 
in  any  way 
dep  en  dent 
upon  the 
meals ;  is  re- 
11  e  V  e  d  by 
pressure  and 
shows  inter- 
vals of  sever- 
al days'  dura- 
tion which 
are  perfect- 
ly free  from 
pain. 

Variable 


Presents  a  nor- 
mal  appear- 
ance. 


do. 
do. 

Not  present 


Shows  no  regu- 
larity in  its 
appearance. 


No  vomiting  of 
blood. 


Hyper- 
chlorhydria. 


Met  with  in  all 
periods  of 
life,  except  in 
youth,  when 
it  is  quite 
rare. 

More  frequent 
in  men. 

The  pain  a  p  - 
pears  about 
two  to  three 
hours  after 
meals  and 
disa  p  p  e  a  r  s 
after  partak- 
ing of  some 
food  (espe- 
cially meat, 
mUk,  egg)  or 
after  the  ad- 
ministration 
o  f  bicarbo- 
nate of  soda. 


Often      in 
creased. 


Is  either  clean 
or  slightly 
furred. 


do. 
do. 


Water  brash 
and  pyrosis 
quite  f  r  e  - 
quent. 

No  vomiting. . 


No  vomiting  of 
blood. 


Cancer. 


Middle  age  and  ad- 
vanced life. 


No  marked  differ- 
ence between  the 
two  sexes. 

The  pain  is  less  in- 
tense in  char- 
acter but  more 
steady;  there  are 
seldom  free  in- 
termissions dur- 
ing which  no  dis- 
tress is  felt  in  the 
gastric  region. 


Appetite,  as  a  rule, 
very  poor. 


Almost    a  1  w  a  y  I 
thickly  coated. 


Very  often  bitter 
or  sour. 

As  a  rule  present 
and  very  often 
associated  with  a 
dis  agreeable, 
even  fetid  odor. 

No  water  brash; 
pyrosis  quite  in- 
tense. 

The  vomiting,  as  a 
rule,  occurs  not 
after  each  meal 
but  once  or  twice 
a  day  or  once  in 
two  days,  the 
quantity  being 
often  veiT  large. 

Vomiting  of  blood 
occurs ;  the 
quantity  is  rela- 
tively small,  the 
color  ordinarily 
coffee  brown. 
The  blood  a  p  - 
pears  in  a  decom- 
posed condition, 
presenting  f  r  e  - 
quently  a  fetid 
odor.  The  vomit- 
ing often  recurs 
with  short  inter- 
missions. 


DISEASES   OF   THE   STOMACH. 


Gastric  ulcer. 


Xervous 
^astralgia. 


Hyper- 
chlorhydria. 


Cancer. 


Secret 
function 


Tumor. . 


Pe  r  f  o  r  a 

tiOD. 


ory  J 


Gastric  juice  as  a  Variable., 
rule  increased. 
2.  Lactic  acid    ab-  Absent  . . . 
;,        sent. 

No  tumor;  r  are  ly,iNo  tumor 
however,     if    the 
ulcer  is  near  the 
pylorus,  the  latter 
becomes  thickened 
and  can  be  felt  as 
a  smooth,  lengthy 
body. 
Perforation    m  i  g  h  t  No  perforation. 
take  place  after  a 
short  period  of  ill-: 
ness.  ! 

Ci"'mpl e X -  Complexion    com  -  Complex! on 
ion.  monly    fresh,    but     pale, 

anaemic    after   se- 
vere losses  of  blood 


Increased As  a   rule,    highly 

decreased. 
Absent As  a  rule,  present. 


No  tumor. 


No  perforation. 


Complexion 
pale. 


Tumor  very  fre- 
quently palpable; 
presenting,  a.s  a 
rule,  an  uneven 
surface;  is  pn'm- 
ful  to  pressure 
and  easilv  mova- 
ble. 

Perforation  occurs 
only  in  the  last 
stages  of  the 
disease. 

Complexion  sallow 
and  yellowish; 
skin  dry ;  marked 
cachexia. 


Localization  of  the  Ulcer. — As  above  mentioned  in 
speaking  of  the  pathology,  the  ulcer  may  be  situated 
at  different  points  of  the  stomach  walls,  or  at  the 
pylorus,  the  beginning  of  the  duodenum,  the  cardia, 
or  the  lower  end  of  the  oesophagus.  The  exact  site 
of  the  ulcer  can  be  determined  with  certainty  only  in 
rare  instances.  Most  frequently  we  remain  in  doubt 
with  reference  to  this  point  of  diagnosis.  There  are, 
however,  several  symptoms  which  can  be  utilized  with 
regard  to  a  probable  diagnosis  as  to  the  situation  of 
the  ulcer.  1.  Frequently  patients  experience  relief 
from  their  pains  in  assuming  a  certain  position. 
Thus,  for  instance,  some  feel  easier  in  lying  on  the 
back,  others  less  uncomfortable  when  they  lie  upon 
their  abdomen.  Again,  some  feel  no  pain  in  stand- 
ing, but  the  latter  appears  when  they  assume  a  re- 
cumbent position.  In  a  few,  again,  this  is  re- 
versed, the  pain  appearing  in  the  standing  and  disap- 
pearing in  the  recumbent  position.  As  a  rule,  we 
may  assume  that  the  position  in  which  the  patient  is 


ULCER   OF   THE   STOMACH.  223 

most  comfortable  is  the  one  which  permits  the  ulcer  to 
remain  above  the  gastric  contents,  and  to  come  least 
in  contact  with  them.  Hence  an  ulcer  situated  at  the 
lesser  curvature  will  be  diagnosed  if  the  patient  ex- 
periences relief  in  standing.  Again,  an  ulcer  of  the 
greater  curvature  will  be  suspected  if  the  pain  is  most 
intense  on  standing.  The  site  of  the  ulcer  will  be  sus- 
pected to  be  in  the  cardiac  portion  of  the  stomach  if 
the  patient  has  less  pains  when  lying  on  his  right  side, 
and  in  the  pyloric  region  if  the  pains  are  less  severe 
when  he  occupies  a  left-sided  position.  2.  Pains  ap- 
pearing directly  after  the  deglutition  of  food,  and  as- 
sociated with  vomiting  immediately  after  meals,  par- 
ticularly point  to  an  ulcer  in  the  cardiac  region  or  in 
the  lowest  part  of  the  oesophagus.  3.  Pains  appearing 
two  or  three  hours  after  meals,  referred  partly  to  the 
right  of  the  epigastric  region  and  associated  with 
melsena  (bloody  stools),  point  to  the  situation  of  the 
ulcer  either  at  the  pylorus  or  the  beginning  of  the 
duodenum. 

Prognosis. — At  first  glance  it  would  appear  that  the 
prognosis  of  gastric  ulcer  is  quite  good,  especially  now- 
adays, when  the  diagnosis  of  the  affection  is  usually 
made  at  an  early  date.  However,  if  we  take  into 
consideration  the  tabulated  statistics  given  by  Debove 
and  Eemond '  in  reference  to  the  outcome  of  all  cases 
of  ulcer,  we  will  become  more  careful  in  our  favorable 
predictions.  This  table  gives  in  a  hundred  cases  of 
ulcer : 

Perfect  cure, 50 

Perforations  and  peritonitis,  ....         13 
Foudroyant  hasmaternesis,       ....  5 

*  Cited  from  Debove  et  Reroond  :   I.  c,  p.  376, 


224  DISEASES   OF   THE   STOMACH. 

Pulmonary  tuberculosis,  ....         20 

Inanition, 5 

Different  complications,  ....  7 

Treatment  of  Gastric  Ulcer. — Crnveilhier,  to  whom 
we  are  indebted  for  the  first  thorough  and  accurate 
description  of  gastric  ulcer,  recommended  milk  as  the 
most  suitable  food  in  this  condition,  and  although 
many  decades  have  since  passed,  milk  still  stands  first 
in  the  dietary  of  these  patients. 

As  rest  is  the  foremost  auxiliary  in  the  treatment  of 
most  diseases,  it  appears  natural  to  make  use  of  this 
agent  in  ulcer.  Leube  and  Ziemssen  '  deserve  credit 
for  having  laid  so  much  stress  on  this  point  and  for 
having  devised  the  "rest  cure-'  for  the  treatment  of 
ulcer.  Although  this  mode  of  treatment  had  been 
practised  long  ago  by  W.  Fox^  and  B.  Forster  in  Eng- 
land, still  Leube  and  Ziemssen  have  succeeded  in  pop- 
ularizing the  same,  and  that  is  the  reason  why  it  justly 
bears  their  name. 

The  Leube-Ziemssen  rest  cure  for  the  treatment  of 

ulcer  consists  in  the  following:     The  patient  is  kept 

abed  for  two  to  three  wrecks.     He  is  poulticed  during 

the  day  with  flaxseed  (warm)  over  the  stomach  and 

the  upper  part  of  the  abdomen ;  at  night  a  priessnitz 

(wet   linen   cloth)    is  substituted,  covering   the  same 

area.     The  diet  consists  of  liquids — milk,  milk  with 

strained  barley,  or  oatmeal,  or  rice  water,  plain  water, 

weak  tea,  and  peptone  (one  teaspoonful  to  a  cup  of 

water).     Debove   and    Remond '  have   suggested  the 

addition  of  lactose  and  of  meat  powder  to  the  milk, 

in  order  to  make  the  diet  richer  in  nourishing  sub- 

'  Leube  :  I.  c,  p.  120.  ^  Debove  et  Remond  :  I.  c,  p.  284. 

*  Wilson  Fox  ;  Z.  c. 


ULCER   OF   THE    STOMACH.  225 

stances.      As   a   rule,    we    employ   the   above-named 
additions,  which  fulfil  the  same  purpose,  besides  vary 
ing  the  monotonous  bill  of  fare. 

During  the  first  week  we  give  the  patient  half  a  cup 
(about  100-150  c.c.)  of  either  every  hour.  Every- 
thing the  patient  takes  must  be  neither  cold  nor  very 
warm,  and  should  be  taken  slowly  (sipping  or  with  a 
spoon).  During  the  second  week  we  order  the  same 
kind  of  food,  with  this  difference,  that  he  is  nour- 
ished every  two  hours,  and  gets  a  cupful  or  a  cupful 
and  a  half  (200-300  c.c.)  at  a  time.  Occasionally  we 
now  allow  the  patient  one  raw  egg  beaten  up  in  the 
milk,  once  or  twice  a  day. 

In  the  beginning  of  the  third  week  we  feed  the  pa- 
tient every  three  hours;  he  is  allowed  barley,  farina 
and  rice  (well  cooked)  in  milk,  soft-boiled  eggs, 
crackers  softened  in  milk,  in  addition  to  his  previous 
food  ;  on  the  third  day  of  the  third  week  we  begin  to  give 
the  patient  meat,  first  raw,  well  scraped,  then  broiled. 
Thereafter  we  go  over  to  the  ordinary  daily  diet,  ex- 
cluding heavy  salads,  pastry,  raw  fruit,  and  the  like. 

In  the  following  table  I  give  an  outline  of  diet  which 
I  ordinarily  prescribe  in  this  affection ; 

Outline  of  Diet  in  Gastric  Ulcer. 


FIRST  THREE  DAYS. 

Numbei  of 
calories. 

7 

A.M. 

:  milk,  150  c.c.  (five  ounces), 

, 

, 

.  101 

8 

ii 

((                 a                  a              a 

, 

, 

.  101 

9 

a 

il                        (C                         i(                    il 

, 

, 

.  101 

10 

a 

milk   and   strained    barley 

water 

(each), 

150  CO.,  .... 

, 

.     80 

11 

a 

milk,  150  c.c,   . 

. 

, 

.  101 

12 

« 

15 

• 

• 

.   101 

226 


DISEASES   OF   THE    STOMACH. 


Number  - 
calorie^ 


1    P.M. 


2  " 

3  " 

4  " 

5  " 
6,  7,  8, 


bouillon  either  alone  or  with  the  addition 
of  one  to  two  teaspoonfuls  of  a  peptone 
preparation,  150  c.c,       .         .         .         .30 


milk, 


milk  with  strained  barley  or  oatmeal, 
9  p.m.:  milk,  150  c.c, 


101 
101 
101 

80 
404 

1,402 


7    A.M. 
9      " 
11      " 

1    P.M. 

3     " 
5     " 

9     " 


FOURTH  TO  THE  TENTH  DAY. 

milk,  300  c.c.  (ten  ounces), 


Number  of 
calories. 

.   202 
.   202 


"     with  barley,  rice,  or  oatmeal  water, 
300  c.c, 160 


one  cup  of  bouillon,  200  c 
beaten  up  in  it, 
milk,  300  c.c,    . 


c,  and  one  egg 


with  barley  water,  300  c.c., 
300  c.c,    .... 


.  80 
.  202 
.  202 
.  160 
.  202 

1,410 


7  A.M. 

9   " 

11   " 

1  P.M. 

3   " 
5   " 

/»<   (( 
9   " 


ELEVENTH  TO  THE  FOURTEENTH  DAY. 

milk,  300  C.C,  . 


Number  of 
calories. 


202 

202 

and  two  crackers  softened  (one  ounce),      .  100 
milk  with  barley  water,  300  c.c,       .         .  160 
one  cup  of  bouillon,  200  c.c,  one  Q^^,  and 
two  crackers,  .         .         .         .         .         .180 

milk,  300  c.c,  and  one  egg,       .         .         .  282 

202 

and  two  crackers,  .  .  .  .  .100 
milk  with  barlej^  water,  .  .  .  .160 
milk,  300  c.c, 202 


1,790 


ULCER   OF   THE   STOMACH. 


227 


FOURTEENTH  TO  THE  SEVENTEENTH  DAY, 


7  A.M. :   milk,  300  c.c,  . 
9 

and  two  crackers  (one  ounce), 
11     "       milk  with  barley,  300  c.c, 
1   P.M. :   scraped  meat,  50  gm., 


two  crackers ;  one  cup  of  bouillon,  200  c.c,  100 
milk,  300  c.c,    . 


one  egg  (soft  boiled), 
two  crackers, 

milk  with  farina,  300  c.c, 
"     300  cc,      . 


Number  of 
calories. 

.  202 

.  202 

.  100 

'.  342 

.  60 


.  202 
.  202 
.  80 
.  100 
.  342 
.  202 

2,134 


SEVENTEENTH  TO  TWENTY-FOUETH  DAY. 


Number  of 
calories. 


7  A.M. :  two  eggs  (soft  boiled),       .        .        .         .160 

butter,  10  gm.,  .         .         .         .         .         .81 

toasted  bread,  60  gm.,        .         .         .         .130 

milk,  300  c.c, 202 

10     «  "  " 202 

crackers,  50  gm.,  .  .  .  .  .  166 
butter,  20  gm., 162 

1  P.M. :  lamb  chops  (broiled)  50  c.c,  .  .  .60 
mashed  potatoes,  50  gm.,  .         .         .44 

toasted  bread,  50  gm.,  .  .  .  .130 
butter,  10  gm. ;  one  cup  of  bouillon,  200  c.c,     81 

4     "       the  same  as  at  10  A.M.,      ....  530 


6:30  P.M. :  milk  with  farina,  300  cc, 
crackers,  50  gm.,  . 
butter,  20  gm., 

9  "       milk,  300  c.c, 


.  342 

.  166 
.  162 

.   202 


2,820 


At  the  beginning  of  the  third   week  the  flaxseed 
poultices  are  discontinued  and  the  patient  is  allowed  to 


228  DISEASES  OF  THE   STOMACH. 

be  up,  first  for  a  short  time  only  (half  an  hour  to 
an  hour),  then  for  several  hours,  and  afterward  for 
the  whole  day.  At  the  beginning  of  the  fourth  week 
the  patient  may  begin  to  walk  outdoors  and  gradually 
resume  his  daily  work. 

Leube  and  Ziemssen  and  most  of  the  German  writers 
recommend  the  use  of  either  Carlsbad  water  (half  a 
pint)  or  Carlsbad  salt,  5  to  10  gm.  in  the  same  quantity 
of  water,  heated  to  122°  F.,  twice  daily  (the  first  por- 
tion being  taken  in  the  morning,  the  second  at  night 
before  going  to  sleep).  I  do  not  believe  that  the 
Carlsbad  salt  is  in  any  way  essential.  In  most  of 
my  cases  of  gastric  ulcer  I  have  omitted  the  so-called 
Carlsbad  drink  cure,  and  have  obtained  results  equally 
satisfactory  as  when  the  salt  was  employed. 

In  cases  of  ulcer  of  the  stomach  presenting  a  more 
severe  type — violent  pains,  frequent  vomiting,  inabil- 
ity to  take  food  on  account  of  the  pains — or  after 
haematemesis,  I  usually  have  the  patient  abstain  from 
any  food  whatever,  given  by  the  mouth,  for  a  period 
of  five  days.  The  patient  is  then  fed  by  the  rectum. 
This  is  done  in  the  following  way :  Early  each  morn- 
ing the  patient  receives  a  large  enema  of  about  a 
quart  of  lukewarm  water  in  which  a  teaspoonful  of 
common  table  salt  has  been  dissolved  as  a  cleansing 
enema.  About  an  hour  after  the  patient  has  emptied 
the  injected  water  the  first  nourishing  enema  is  given ; 
this  may  consist  either  of  a  glassful  of  milk  (about 
200  c.c.)  in  which  a  raw  egg  has  been  well  beaten 
and  a  pinch  of  salt  added,  or  of  a  cupful  of  water  in 
which  a  tablespoonful  of  a  good  peptone  preparation 
has  been  dissolved.     The  temperature  of  either  must 


ULCER   OF   THE    ST03IRCH,  229 

be  about  100°  F.  Such  a  nourishing  enema  is  given 
three  or  four  times  a  day.  The  quantity  of  the  feed- 
ing enema  is  200-250  c.c,  and  it  is  slowly  injected  by 
means  of  a  fountain  syringe  and  a  soft-rubber  rectal 
tube.  The  patient  may  frequently  wash  his  mouth 
with  cold  water,  and  is  allowed  from  time  to  time  to 
keep  a  small  piece  of  chopped  ice  in  his  mouth,  and  to 
swallow  the  melted  water.  The  five  days  being  over, 
the  mode  of  diet  is  the  same  as  described  above  for 
the  ordinary  form  of  ulcer. 

Whenever  the  "rest  cure"'  is  applied  there  is  scarcely 
any  need  for  constant  medicinal  treatment.  Some- 
times, however,  we  make  use  of  a  small  dose  of  codeine 
if  the  pains  are  very  severe,  and  of  Carsbald  salt  if 
there  is  constipation.  Only  in  cases  where  the  ulcer 
is  associated  with  a  hyperacid  gastric  juice  may  we 
regularly  administer  an  alkaline  salt,  as  for  instance: 

:^  Magnes.  ust., 5.0  (  3  i.) 

Sod.  carbon,  exsiccat. , 

Sod.  bicarbon., 

El^osaccli.  menth.  pip.,        .         .         .         .  aa  15.0  (  §  ss. ) 
M.  exactissime,  f .  pulv.     D.  ad  scatulam.     S.  A  tip  of  a  knife 
every  two  hours. 

In  chlorotic  individuals  the  administration  of  an  or- 
ganic iron  preparation  (as  for  instance  Pizzala's  or 
Dietrich's  Elixir  of  peptonate  of  iron  or  Boehringer's 
ferratin)  is  often  ver}'  serviceable.  Thus  far  we  have 
spoken  only  of  patients  who  can  submit  to  the  bed 
treatment.  In  patients  who  cannot  afford  to  stay  in 
bed,  the  following  two  methods,  which  are  at  jDresent 
in  vogue,  may  be  tried.  I  have  practised  both  of  them, 
sometimes  with  good  results. 

The  one   is   the   ^'nitrate-of-silver"  treatment,   the 


230  DISEASES   OF   THE   STOMACH. 

other  the  "bismuth"  treatment.  During  the  use  of 
either  of  these  remedies  the  patient  is  allowed  to  at- 
tend to  his  business  and  partake  of  a  light  diet,  in 
which  milk  plays  a  prominent  part. 

I.  The  silver  nitrate  is  given  first : 

I^  Argent,  nitr 0.3  (gr.  v.) 

Aq.  dest., 180.0  (svi.) 

D.  in  vitro  nigro.     S.  A  tablespoonful   in   a   wineglassful  of 
water  three  times  a  day,  half  an  hour  before  meals. 

After  having  used  up  this  quantity,  the  dose  may  be 
gradually  increased,  prescribing  0.4-0.6  gm.  of  silver 
nitrate  to  180  of  water.  The  silver  nitrate  may  be 
used  in  the  way  mentioned  for  about  two  or  three 
weeks,  and  is  then  discontinued.  The  pains  usually 
disappear  after  the  completion  of  the  first  week's  medi- 
cation. 

II.  The  subnitrate  of  bismuth.  The  bismuth  has 
been  used  again  and  again  in  painful  affections  of  the 
stomach,  the  dose  being  from  0.2  to  1.0  gm.  several 
times  daily.  The  French  physicians  recommended  the 
use  of  much  larger  doses,  giving  5  gm.  three  times 
daily.  Fleiner '  has  lately  laid  much  stress  on  the  use 
of  large  doses  of  bismuth,  suspended  in  water,  in  the 
treatment  of  ulcer,  and  Rosenheim  ^  corroborated  his 
views.  I  had  the  opportunity  of  applying  this  method 
quite  frequently  and  was  satisfied  with  the  results. 

We  may  give  the  patient  from  3  to  5  gm.  of  bismuth 
three  times  a  day,  to  be  taken  in  a  wineglassful  of 
water,  well  shaken,  half  an  hour  before  meals.  It  is 
best  to  have  the  patient  lie  quietly  for  about  half  an 

1  Fleiner  :  Verhandl.  des  XII.  Congresses  f.  innere  Medicin,  1893. 
^Rosenheim:  "Die  neueren  Behandlungsmethoden  des  Magens." 
Berliner  Klinik,  May,  1894. 


ULCER   OF   THE   STOMACH.  231 

hour  after  having  partaken  of  the  powder.  The  bis- 
muth treatment  must  be  continued  for  about  two  or 
three  weeks  without  interruption.  It  is  remarkable 
that  these  large  doses  of  bismuth  do  not,  as  a  rule, 
cause  constipation.  In  all  of  my  cases  with  but  few 
exceptions  the  bowels  moved  every  day  without  the 
aid  of  any  cathartic  during  the  whole  time  of  the  bis- 
muth medication.  The  bismuth  treatment  in  ulcer 
seems  to  me  to  deserve  high  recommendation. 

Hemorrhage. — In  cases  of  hemorrhage  from  the 
stomach  the  treatment  is  the  same  as  in  the  severe 
type  of  ulcer,  with  the  exception  that  ice-cold  ap- 
plications are  made  over  the  stomach  instead  of  the 
warm  poultices.  Perfect  rest  is  here  absolutely  neces- 
sary. The  patient  must  keep  very  quiet  and  avoid 
any  motion  whatever ;  even  turning  from  one  side  to 
the  other  is  not  permissible.  The  patient  should  be 
prohibited  all  conversation  except  it  be  to  indicate  his 
wants. 

If  the  hemorrhage  be  profuse  'or  if  there  are  signs 
that  the  bleeding  has  not  yet  come  to  a  standstill, 
hypodermic  injections  of  ergot  are  advisable.  One 
Pravaz  syringe  of  the  following  should  be  injected 
two  or  three  times  a  day  in  the  gastric  region : 

I^  Extr.  secal.  cornut., 2.5  (3  ss.) 

Aq.  dest. , 

Glycerin., aaS.O  (3i.) 

Chloride  of  iron  (5-15  drops  in  water)  and  acetate 
of  lead  0.05  gm.,  one  powder  every  two  hours, 
which  in  olden  times  were  used  so  frequently,  do  not 
in  reality  have  much  effect. 

In  case  the  hsematemesis,  however,  recurs  frequent- 


232  DISEASES   OF   THE   STOMACH. 

ly,  and  the  patient  is  running  the  risk  of  bleeding  to 
death,  Ewald '  recommends  resort  to  lavage  with  ice- 
cold  water.  For  this  purpose  the  j^harynx  must  first 
be  well  cocainized,  and  the  washing  of  the  stomach 
then  performed  with  the  greatest  care. 

Collapse. — In  case  the  patient  has  sunk  into  a  col- 
lapsed condition,  camphor  or  ether  should  be  hypo- 
dermically  injected.  An  enema  of  warm  wine  or 
warm  wine  with  egg  should  be  administered,  and  a 
hot-water  bag  applied  to  the  feet.  In  those  instances 
where  the  high  degree  of  anaemia  endangers  the  life 
of  the  patient,  transfusion  of  blood  was  formerly  fre- 
quently resorted  to.  Nowadays  a  subcutaneous  injec- 
tion of  a  physiological  salt  solution  (4  to  6  NaCl  to 
aq.  dest.  1,000),  in  quantities  from  a  pint  to  a  litre, 
is  used.  The  solution  and  the  apparatus  (fountain 
syringe)  must  be  thoroughly  sterilized,  and  one  or 
two  quite  thick  Pravaz  needles  used.  The  solution, 
warmed  to  blood  temperature,  is  then  injected  into 
the  subclavicular  region. 

Perforation. — If  perforation  has  occurred  perfect 
rest  is  absolutely  necessary ;  nothing  should  be  given 
by  the  mouth,  ice  bags  should  be  placed  over  the  abdo- 
men, and  large  doses  of  opium,  preferably  in  the  form 
of  suppositories,  should  be  administered.  In  cases  in 
which  the  stomach  contains  large  quantities  of  food, 
Ewald  suggests  the  washing  out  of  the  stomach,  per- 
formed after  cocainization  of  the  pharynx  and  with  all 
other  necessary  precautions.  As  soon  as  the  symptoms 
of  collapse  appear,  the  above-described  treatment  is 
employed.     The  prognosis  of  perforation  being  so  very 

1  C.  A.  Ewald  :  I   c,  p.  274. 


ULCER   OF   THE   STOMACH.  233 

unfavorable,  notwithstandiDg  all  medicinal  treatment, 
resort  has  been  lately  had  to  laparotomy,  in  order 
to  master  the  situation  surgically. 

Surgical  Procedures  in  the  Treatment  of  Gastric 
Ulcer  and  its  Sequelce. — Gastric  ulcer  may  occasion- 
ally take  a  very  obstinate  course,  not  being  amenable 
to  medical  treatment.  Again,  its  complications, 
hemorrhage  (which  may  become  very  abundant  or 
frequent)  and  perforation,  greatly  endanger  life;  the 
latter,  in  fact,  almost  always  terminating  fatally. 
Barling '  says  that  ninety-five  per  cent  of  the  patients 
having  such  perforations  die,  unless  operated  upon. 
For  this  reason  Nelson  C.  Dobson'  in  1883  advocated 
operative  interference  for  a  perforating  ulcer  accord- 
ing to  one  of  the  following  methods.  1.  Simple  ab- 
dominal section  with  cleansing  of  the  peritoneum, 
leaving  the  ulcer  to  heal  of  itself  under  rest  and 
rectal  feeding.  2.  The  closure  of  the  perforation  bj^ 
suture,  either  with  or  without  paring  its  edges.  3. 
The  suture  of  the  stomach  at  the  point  of  perforation 
to  the  abdominal  wall,  in  order  to  establish  a  gastric 
fistula. 

A  few  years  later  this  mode  of  treatment  was  car- 
ried out  by  several  surgeons  in  Europe  and  this 
country. 

Eobert  F.  "Weir,"  of  New  York,  was  among  the  first 
who  operated  in  this  country.     His  latest  report  of  a 

'  Barling  :  Birmingham  Medical  Eeview,  August,  1895. 

2  Dobson  :  Bristol  Medical  and  Surgical  Journal,  1893,  p.  196. 

3 Robert  F.  Weir  and  E.  M.  Foote :  "The  Surgical  Treatment  of 
Round  Ulcer  of  tlie  Stomach  and  its  Sequelae,  with  an  Account  of  a 
Case  Successfully  Treated  by  Laparotomy."  Medical  News,  April 
25th  and  May  2d,  1896. 


;>o4  DISEASES   OF   THE   STOMACH. 

successful  operation  of  this  kind  deserves  the  highest 
commendation.  We  deem  it  of  great  value  to  report 
this  case  in  Dr.  Foote's  own  words. 

"Mary  B consulted  me  in  August,  1894,  for  an 

obstinate  cough,  with  scanty  expectoration  and  pain 
in  the  sternal  and  right  scapular  region,  with  dyspnoea 
on  exertion,  headache,  anorexia,  and  constipation. 
She  had  twice  spit  up  a  small  amount  of  blood.  For 
four  months  she  had  had  night  sweats.  The  patient 
was  at  that  time  15  years  old,  heavy  but  ansemic. 
Physical  examination  showed  dulness  and  fine  moist 
rales  at  the  left  apex,  and  right  base  behind,  and  she 
had  an  afternoon  fever.  Under  tonic  and  expectorant 
remedies,  and  a  month's  residence  in  the  mountains 
of  Sullivan  County,  N.  Y.,  she  gained  weight  and  the 
rales  disappeared,  except  at  the  base  of  the  right  lung. 
The  following  winter  she  neglected  herself,  and,  when 
I  next  saw  her  in  April,  1895,  her  cough  was  worse, 
and  she  had  moist  rfdes  over  the  greater  part  of  both 
lungs,  and  she  had  lost  six  pounds  in  weight.  Though 
living  in  poverty,  she  was  able,  through  friends,  to 
spend  three  months  of  the  summer  in  the  mountains, 
and  she  did  not  return  to  the  city  until  the  last  of 
September,  1895,  when  she  took  a  position  as  maid  in 
an  apartment,  where  the  work  was  light  and  her  food 
good.  Her  health  was  excellent,  the  cough  and  rales 
had  disappeared,  and  her  weight,  one  hundred  and 
ten  and  a  half  pounds,  was  greater  than  it  had  ever 
before  been.  I  was  never  able  to  secure  any  sputum 
for  examination,  but  the  signs  of  pulmonary  tubercu- 
losis had  been  too  well  marked  to  be  doubted. 

'"She  had  frequently  been  troubled  with  indigestion, 
and  at  various  times  had  vomited  her  food,  but  these 
symptoms  had  not  been  the  prominent  ones.  About 
November  20th,  1895.  she  began  to  have  severe  gastric 


ULCER  OF   THE   STOMACH.  235 

pain,  and  her  appetite  failed  her.  She  spoke  to  no  one 
about  it  and  kept  on  with  her  work,  though  eating 
almost  nothing.  The  pain,  too,  was  at  times  so  severe 
that  she  was  compelled  to  lie  down.  On  November 
27th,  at  10  A.M.,  she  was  attacked  with  a  colicky  pain 
in  the  gastric  region  so  severe  that  she  rolled  upon  the 
door  in  agony,  and  vomited  a  small  amount  of  coffee, 
which  was  the  only  nourishment  she  had  taken  that 
da3^  About  noon  she  felt  a  little  relief  and  went  home 
by  way  of  the  elevated  road.  To  do  this,  she  walked 
about  a  quarter  of  a  mile,  and  climbed  up  and  down 
some  fifty  steps.  Late  in  the  afternoon  she  sent  word 
to  me  that  she  had  an  '  attack  of  pain  in  the  heart.' 
At  6:30  P.M.  I  found  her  lying  on  her  back,  quiet,  and 
without  much  pain.  Pulse,  120;  temperature,  102°, 
The  facies,  though  not  well  marked,  was  of  a  purely  ab- 
dominal type.  The  chest  revealed  nothing  abnormal. 
The  abdomen  was  somewhat  rigid,  and  more  so  on  the 
left  side  than  on  the  right.  There  was  moderate  ten- 
derness on  pressure  in  the  epigastric  and  left  iliac 
regions.  There  was  no  distention  or  tympanites. 
Eespiration  was  almost  wholly  thoracic.  Palpation 
revealed  nothing  but  the  seat  of  tenderness.  The 
pain  was  described  as  commencing  to  the  left  of  the 
median  line  under  the  costal  border,  and  extending 
thence  to  the  left  groin  and  into  the  left  thigh.  Ap- 
pendicitis was  out  of  the  question,  and  the  symptoms 
did  not  appear  to  be  those  of  any  form  of  intestinal 
obstruction.  The  diagnosis  of  perforated  gastric  ulcer 
was  made,  and  an.  immediate  operation  advised.  Dr. 
Weir  kindly  consented  to  admit  the  patient  to  his  ser- 
vice at  the  New  York  Hospital,  where  he  performed 
laparotomy,  and  sutured  the  stomach  at  9:30  p.m.,  a 
little  over  eleven  hours  after  the  onset  of  the  attack. 
"Under  chloroform,  a  median  incision  four  and  one- 


236  DISEASES   OF   THE   STOMACH. 

half  inches  long  was  made  above  the  umbilicus.  An 
unusual  amount  of  subperitoneal  fat  obscured  the 
peritoneum.  When  its  cavity  was  opened  the  stom- 
ach presented  in  the  wound.  The  greater  curvature 
appeared  normal.  There  was  no  general  peritonitis. 
The  anterior  surface  of  the  stomach  was  adherent  to 
the  liver  by  recent  lymph.  As  it  w^as  separated,  a 
hissing  sound  was  heard,  due  to  the  escape  of  gas 
from  the  stomach  through  the  perforation. 

"The  opening  was  found  without  difficulty.  It  was 
minute,  less  than  one-fourth  inch  in  diameter,  with 
necrotic  edges,  and  lying  in  the  centre  of  a  dense  ring 
of  inflammatory  and  fibrinous  tissue,  which  involved 
the  whole  thickness  of  the  wall  of  the  stomach.  This 
thickened  area  was  about  two  inches  long  and  one  inch 
wide,  and  was  situated  in  the  anterior  w^all  of  the 
stomach,  about  midway  between  the  greater  and  lesser 
curvatures,  and  perhaps  one-third  of  the  distance  from 
the  pyloric  to  the  cardiac  orifice. 

"The  operation  lasted  about  one  hour,  and  the 
patient  left  the  table  in  fair  condition,  with  a  pulse 
of  150.  For  two  days  there  was  frequent  and  very 
distressing  vomiting,  temporarily  relieved  by  gentle 
lavage  with  diluted  Thiersch's  solution.  After  the 
second  day  the  vomiting  subsided,  and  water  was 
allowed  by  the  mouth.  Fluid  nourishment  was  given 
on  the  third  day,  and  the  nutrient  and  stimulant  ene- 
mata,  which  had  been  given  every  six  hours  following 
the  operation,  were  stopped  in  four  days.  There  w^ere 
at  no  time  any  signs  of  general  peritonitis.  Eecovery 
was  otherwise  uneventful." 

In  his  exhaustive  paper.  Weir  gives  a  table,  con- 
taining seventy-two  cases  of  laparotomy  for  acute 
perforation  of  gastric  ulcer.  Among  the  names  of 
operators  in  America  we  notice  F.  Markoe,  Robert  F. 


ULCER   OF   THE   STOMACH. 


237 


Weir,  C.  P.  Parker,  McCosh,  Kirkpatrick,  Armstrong, 
and  Stimson. 

With  regard  to  the  results  of  operative  treatment 
Weir  furnishes  the  following  table,  which  clearly 
illustrates  the  importance  of  early  surgical  interfer- 
ence: 


Elapsed  time. 

Recovery. 

Death. 

Mortality 
per  cent. 

Under  twelve  hours 

14 
4 
4 

1 

9 
13 
28 

5 

39 

Twelve  to  twenty-four  hours. 

Over  twenty-four  hours 

Not  stated 

76     . 

87 

Total 

23 

55 

71 

The  operations  above  mentioned  for  the  tteatment 
of  a  perforating  gastric  ulcer  will  also  prove  applicable 
for  a  perforating  ulcer  of  the  duodenum.  A  success- 
ful case  of  operation  in  the  latter  instance  has  recently 
been  reported  by  A.  Landerer  and  G.  Gliicksmann.' 

Surgical  procedures  have  also  lately  been  advised 
for  the  treatment  of  very  obstinate  cases  of  gastric 
ulcer,  consisting  in  excision  of  the  latter  or  in  the 
establishment  of  a  gastro-enterostomy.  Severe,  per- 
sistent pains  due  to  the  formation  of  adhesions  as 
sequelaa  of  gastric  ulcer  have  also  been  relieved  surgi- 
cally by  separating  them  (Lauenstein).^ 

^  A.  Landerer  und  G.  Glticksmann :  "Mittheilungen  aus  den 
Grenzgebieten  der  Medizin  und  Chirurgie, "  Bd.  i.,  p.  168.  Jena, 
1896. 

^  Lauenstein :  Arch,  f .  klin.  Chirurgie,  vol.  xlv. 


OHAPTEE   YII. 

ORGANIC     DISEASES     WITH     CONSTANT 
IjESI01:sS. —Conti7iued. 

Erosions  of  the  Stomach. 

Definition. — A  condition  in  which  the  gastric  mu- 
cous membrane  becomes  the  seat  of  small  superficial 
exfoliations. 

General  Remarks. — As  is  well  known,  the  term 
"  erosion"  signifies  a  defect  of  sui^erficial  nature.  In 
the  stomach  erosions  are  often  found  at  the  autopsy. 
Of  late  several  valuable  papers  on  the  pathological 
anatomy  of  this  subject  and  on  the  rare  occurrence  of 
erosions  associated  with  typical  ulcers  of  the  stomach 
have  been  published. 

In  his  excellent  article,  "  Ueber  geschwiirige  Pro- 
cesse  im  Magen,"  D.  Gerhardt '  describes  erosions  of 
the  stomach  in  the  following  words:  "Sections  made 
of  erosions  as  a  rule  show  that  at  the  base  of  the 
ulcerations  almost  the  entire  lower  half  of  the  mucous 
membrane  is  still  preserved.  In  the  epithelium  of 
these  remaining  glands  nothing  remarkable  can  be 
discovered ;  at  the  sides  the  glands  become  longer ;  the 
first  ones  that  are  intact  usually  curve  themselves 
over  the  defect  and  partly  cover  it.  The  recovery 
seems  to  take  place  by  the  simple  after-growth  of  the 
gland  remnants." 

'  D.  Gerhardt:  Virchow's  Archiv,  Bd.  127,  p.  85. 


EROSIONS   OF   THE   STOMACH.  239 

While  the  subject  in  question  has  been  thoroughly 
discussed  and  studied  in  respect  to  the  pathological 
anatomy  by  Gerhardt,  Virchow/  Langerhans,'  Hart- 
tung,'  and  Ewald/  very  little  has  been  done  clini- 
cally. Although  erosions  of  the  mucous  membrane 
of  the  stomach  are  mentioned  in  some  text-books, 
there  is  nowhere  defined  how  these  conditions  may  be 
recognized  during  life. 

In  the  Medical  Record  of  June  23d,  1894,  I  have 
published  an  article  which  embodied  observations  on 
seven  patients  in  whom  small  particles  of  gastric  mu- 
cous membrane  were  frequently  found  in  the  wash- 
water  of  the  stomach.  These  cases  resembled  each 
other  in  so  many  respects  that  they  appeared  as  if  be- 
longing to  one  disease.  They  could  best  be  considered 
as  erosions  of  the  gastric  mucous  membrane. 

The  description  of  "erosions  of  the  stomach" 
which  I  shall  give  in  the  following  is  based  on  the 
paper  just  mentioned. 

Etiology. — In  the  vast  majority  of  cases  chronic 
gastric  catarrh  is  probably  the  cause  of  the  origin  of 
the  erosions.  In  some  instances  the  erosions  may, 
however,  be  due  to  some  factors  yet  unknown. 

Symptomatology. — The  subjective  symptoms  are 
especially  pronounced  and  consist  of  pain,  emaciation, 
and  a  feeling  of  weakness. 

ThQ  loains,  which  are  not  usually  intense,  occur  im- 
mediately after  meals,  independent  of  the  character  of 

'  R.  Virchow  :  Virchow's  Archiv,  Bd.  5,  p.  363. 

2  B.  Langerhans :  Virchow's  Archiv,  Bd.  124,  p.  373. 

2  0.  Harttung:  Deutsche  med.  Wochenschr.,  1890,  No.  38,  p.  847. 

^C.  A.  Ewald:  "Diseases  of  the  Stomach,"  p.  236,  1892. 


240  DISEASES   OF   THE   STOMACH. 

the  food  of  which  the  patient  has  partaken.  They 
persist  for  a  variable  period  of  time  (one  to  two  hours) 
and  disappear  gradually.  We  have  never  observed 
cases  characterized  by  severe  attacks  of  pain.  Inter- 
vals of  complete  freedom  from  pain  of  variable  dura- 
tion occur,  during  which  the  patient  is  perfectly  well. 
In  rare  instances  the  pains  are  constant  and  indepen- 
dent of  the  ingestion  of  food. 

Emaciation. — Most  cases  lose  in  flesh  during  the 
first  period  of  their  sickness,  but  thereafter  keep  up 
their  weight  quite  constantly.  They  look  rather  thin 
in  the  face  (the  jaws  protrude,  the  cheeks  are  thin  and 
somewhat  hollow),  but  do  not  present  that  cachectic 
color  we  are  accustomed  to  meet  in  carcinoma  and 
other  grave  chronic  troubles. 

Feeling  of  Weakness. — All  patients  complain  of  a 
feeling  of  lassitude,  weakness,  lack  of  ambition,  and 
inability  to  work,  and  of  a  decrease  of  bodily  strength. 
These  symptoms  appear  most  markedly  right  after 
meals,  and  decrease  somewhat  a  little  while  afterward 
(one-half  to  one  hour).     In  one  of  my  patients  (G. 

B )  there  usually  appeared,  once  in  a  week  or  in  a 

fortnight,  an  exacerbation  of  these  symptoms  associated 
with  complete  anorexia,  which  lasted  for  about  two 
days.  During  this  period  of  deterioration  the  patient 
was  hardly  able  to  walk. 

Object i veil/  the  following  point  is  of  the  greatest 
importance:  in  washing  the  stomach,  when  the  pa- 
tient is  in  the  fasting  condition,  one  to  four  small 
pieces  of  gastric  mucous  membrane  are  found.  They 
are  about  0.3  to  0.4  cm.  long  and  nearly  as  wide,  and 
present  a  blood-red  color.     Under  the  microscope  one 


EROSIONS   OF   THE   STOMACH.  241 

sees  well-preserved  glands  and  accumulations  of  red 
blood  corpuscles  (see  Fig.  39).  These  pieces  of  gas- 
tric mucosa  are  constantly  found  if  the  stomach  of 
the  patient  is  washed  out  in  the  fasting  condition. 
We  have  not  to  deal  here  with  an  incidental  lesion 
caused  by  the  tube,  for  while,  on  the  one  hand,  this 
sign  is  present  even  if  the  lavage  is  performed  without 
any  aspiration  and  by  means  of  a  soft  tube,  on  the 


^i  ^-J:-^^^ 


Fig.  44.— a  Piece  of  Gastric  ^lucosa  Cpatient  M.  G.),  showing  the  glands  mostly 
vertically  cut,  and  accumulations  of  red  blood  corpuscles  on  the  lower  right-hand 
comer. 

other  hand,  one  could  not  observe  in  a  casual  lesion 
that  constancy  which  is  found  here. 

In  most  cases  blood  is  never  found  in  the  wash- 
water  carrying  the  small  pieces  of  mucous  membrane. 
Only  rarely  has  the  wash-water  a  very  faint  red  color; 
this  occurs  especially  if  coughing  spells  frequently  ap- 
pear during  lavage.  Besides  containing  the  pieces  of 
gastric  mucosa,  the  water  is  then  stained  slightly  red. 

The  pieces  of  gastric  mucosa  which  are  found  in 
the  wash-water  of  these  patients  probably  partly  or 

16 


'242  DISEASES   OF   THE   STOMACH. 

wholly  peel  off  from  the  mucous  membrane  of  the 
stomach  some  time  previous  to  the  washing.  This 
would  explain  why  there  is  iio  bleeding  during  the 
lavage.  The  spots  on  which  the  exfoliations  take 
place  and  which  thus  j^resent  "erosions,"  may  explain 
the  soreness  met  with  in  these  patients.  One  can  also 
easily  understand  the  appearance  of  blood  from  the 
sore  spots  caused  by  violent  contractions  of  the  stom- 
ach during  a  coughing  spell. 

It  is  very  difficult  at  present  to  decide  whether  the 
exfoliations  always  take  jDlace  at  the  same  spots — 
the  mucous  membrane  constantly  becoming  replaced 
and  peeling  off — or  whether  the  whole  (or  a  great 
part)  of  the  inner  surface  of  the  stomach  is  affected 
to  such  an  extent  that  small  pieces  of  mucosa  easily 
peel  off  here  and  there.  This  question  can  only  be 
answered  after  a  long  study  of  vast  clinical  and  pa- 
thologico-anatomical  material.  These  exfoliations 
take  place  (whether  always  on  the  same  or  on  differ- 
ent spots)  day  by  day  in  the  stomach  of  our  patients, 
and  effect  temporary  erosions. 

Condition  of  the  Gastric  Juice. — In  most  cases  one 
encounters  a  decrease  in  the  HCl  secretion  and  in  the 
acidity  of  the  stomach  contents.  In  some  there  is  al- 
ways found  a  considerable  amount  of  mucus.  Occa- 
sionally, however,  there  is  found  superacidity  caused 
by  an  increased  HCl  secretion. 

Course.— The  course  of  this  pathological  condition 
is  a  very  prolonged  one.  Several  of  the  patients  ap- 
pear to  suffer  from  it  for  many  years.  Although 
there  may  be  intervals  of  perfect  euphoria  (at  the 
same  time  probably  the  inner  layer  of  the  stomach  is 


EROSIOXS   OF   THE   ST0:MACH.  243 

completely  intact)  for  a  longer  or  shorter  period  of 
time,  the  old  symptoms  do,  however,  sooner  or  later 
return. 

One  would  imagine  that  cases  of  erosions  of  the 
stomach  would  present  a  very  fruitful  soil  for  the  de- 
velopment of  ulcers.  This,  however,  does  not  seem  to 
be  the  case,  for  in  none  of  the  patients  was  there 
any  justifiable  supposition  of  an  existing  ulcer  during 
the  long  course  of  the  sickness. 

As  typical  cases  of  this  affection  we  mention  the 
two  following  cases : 

Case  I. —February  11th,   1893.— H.    S ,   aged 

35,  merchant,  suffers  for  two  to  three  years  from 
digestive  troubles.  These  consist  principally  in  the 
appearance  of  pains  right  after  meals ;  the  pains  are 
not  severe;  they  produce,  however,  the  effect  that 
patient  eats  less.  There  is  a  feeling  of  fulness ;  bow- 
els constipated.     Patient  always  feels  weak  and  tired. 

The  examination  reveals:  chest  organs  intact ;  the 
gastric  region  is  sensitive  to  pressure ;  there  is  splash- 
ing sound  extending  two  fingers'  width  below  the 
navel;  right  kidney  movable. 

The  examination  of  the  stomach  contents  one  hour 
after  Ewald's  test  breakfast  showed:  HCl  +  ;  acidity 
=  60. 

February  13th.  —  When  fasting,  stomach  empty. 
Lavage:  in  the  wash-water  three  small  red  pieces  of 
mucous  membrane  are  found.  Spray  with  silver 
nitrate. 

February  lith. — Intragastric  galvanization. 

February  15th. — Lavage:  in  the  wash-water  three 
small  red  pieces  of  mucous  membrane  appear.  A 
fresh  microscopic  specimen  shows  gastric  glands. 
Spray  with  silver  nitrate. 


244:  DISEASES  OP  THE  STOMACH. 

February  16th. — PatieDt  feels  better — i.e.,  he  is 
stroDger,  can  eat  more,  aDd  is  not  troubled  with 
pains.     Direct  galvanization  of  the  stomach. 

February'  ITth.  —  Lavage:  no  pieces  of  mucous 
membrane  are  found.     Spray  with  silver  nitrate. 

February  ISth. — Intragastric  galvanization. 

February  19th. — Lavage:  no  pieces  of  mucous 
membrane.     Spray  with  silver  nitrate. 

February  20th. — Intragastric  galvanization. 

February  21st. — Examination  of  the  stomach  con- 
tents one  hour  after  the  test  breakfast :  HCl  + ; 
acidity  =54;  no  pieces  of  mucous  membrane. 

February  22d. — Direct  galvanization  of  the  stom- 
ach. 

February  23d. — Lavage:  no  pieces  of  mucous  mem- 
brane.    Spray  with  silver  nitrate. 

February  24th. — Intragastric  galvanization.  Pa- 
tient had  to  return  to  his  native  city,  Chicago,  on  ac- 
count of  urgent  business.  As  I  have  recently  heard, 
patient  felt  well  all  the  time  with  but  few  intervals. 

Case  IL— April  19th,   1893. —B.   M.    S ,  aged 

26,  merchant,  complains  for  two  and  a  half  years 
of  digestive  troubles.  At  first  patient  had  lack 
of  appetite,  pains  after  meals,  and  nausea,  but  no 
vomiting.  Feeling  of  weariness  and  fatigue;  consti- 
pation. After  some  continued  treatment  and  a  trip 
to  the  South  the  condition  of  the  patient  imjDroved  for 
a  while;  soon,  however,  it  got  worse  again.  During 
the  last  two  years  patient  has  constantly  pains  right 
after  meals,  with  but  very  few  exceptions,  and  feels 
ver}^  weak.  When  fasting,  patient  as  a  rule  feels 
well. 

Status  prcesens. — Chest  organs  intact :  the  gastric 
region  is  sensitive  to  pressure.  After  drinking  half 
a  glassful  of  water  a  splashing  sound  can  be  produced. 


EROSIONS   OF   THE   STOMACH.  245 

extendiDg  to  one  to  two  fingers'  width  above  the 
navel.  Liver  not  enlarged.  Urine  contains  neither 
sugar  nor  albumin. 

April  20th. — Examination  of  the  stomach  contents 
one  hour  after  Ewald's  test  breakfast  shows:  HCl  +  : 
acidity  =  60 ;  admixture  of  much  mucus. 

Diagnosis. — Gastritis  glandularis  chronica  mucosa. 

April  21st. — When  fasting,  stomach  empty.  Lav- 
age :  in  the  wash- water,  three  red  pieces  of  gastric  mu- 
cous membrane.  (A  fresh  specimen  in  glycerin 
shows  gastric  glands.)     Spray  with  silver  nitrate. 

April  23d. — Intragastric  galvanization, 

April  25th. — ^Lavage:  three  red  pieces  of  mucous 
membrane  appear  in  the  wash-water.  Spray  with 
silver  nitrate. 

April  27th  and  29th. — Direct  galvanization  of  the 
stomach.  Patient  had  to  leave  New  York  on  account 
of  business  and  returned  on  May  lYth, 

May  ISth. — When  fasting,  stomach  empty.  Lav- 
age: three  red  pieces  of  mucous  membrane  are  found 
in  the  wash-water.     Sj)ray  with  silver  nitrate. 

May  20th. — Intragastric  galvanization. 

May  22d. — Lavage:  two  red  pieces  of  mucous  mem- 
brane are  found.     Spray  with  silver  nitrate. 

May  2ith. — Patient  feels  better,  has  a  better  appe- 
tite,  and  hardly  any  pain.  Lavage:  no  pieces  of  mu- 
cous membrane  are  found.     Spray  with  silver  nitrate. 

May  26th. — Direct  galvanization  of  the  stomach. 

May  30th. — Lavage:  no  pieces  of  mucous  mem- 
brane.    Spray  with  silver  nitrate. 

June  2d.  —  Intragastric  galvanization.  Patient 
feels  well  and  is,  therefore,  for  the  present  dismissed. 

Diagnosis. — The  diagnosis  of  erosions  of  the  stom- 
ach is  made  if  the  above-described  subjective  symp- 
toms  exist  and  particles  of  gastric  mucosa  are  fre- 


246  DISEASES   OP   THE   STOMACH. 

quently  found  in  the  wash-water  when  applying 
lavage  in  the  fasting  condition  of  the  patient. 

Treatment. — The  local  treatment  of  the  stomach 
here  plays  a  great  role.  The  astringent  effect  of  ni- 
trate of  silver  solutions  in  similar  more  accessible  af- 
fections led  me  to  apply  this  substance  directly  to  the 
interior  of  the  stomach.  This  can  best  be  achieved 
by  means  of  the  spray.  It  was  on  this  occasion  that 
I  constructed  the  gastric  spray  apparatus  (see  Fig.  36, 
p.  135),  and  recommended  its  use  in  the  field  of  dis- 
eases of  the  stomach.' 

In  fact,  the  good  result  of  this  method  of  treatment 
can  frequently  be  best  shown  in  the  affection  in  ques- 
tion, for  after  the  spraying  has  been  done  several 
times  the  small  pieces  of  gastric  mucosa  cease  to  ap- 
pear. Associated  with  the  objective  symptom  there 
appears  an  amelioration  in  the  subjective  feeling  of 
the  patient;  the  pains  grow  considerabh'  less  or  en- 
tirely disappear,  and  the  strength  increases. 

The  treatment  is  given  in  the  following  way :  First, 
the  stomach  in  a  fasting  condition  is  washed  out  with 
lukewarm  water;  when  all  the  water  has  been  emp- 
tied, the  tube  is  removed  from  the  stomach.  The 
spray  apparatus  is  filled  with  lOc.c.  of  a  0.1  to  0.2  per 
cent  solution  of  nitrate  of  silver,  the  tube  end  dipped 
into  warm  water  and  inserted  into  the  stomach  (length 
of  tubing  50  cm.);  thereupon  the  whole,  or  at  least 
the  greater  part,  of  the  solution  in  the  bottle  is  sprayed  ; 
the  bottle  is  then  opened  and  the  spray  tube  removed 
from  the  stomach. 

I  usually  combine  the  nitrate-of-silver  spray  treat- 

'  M.  Einhom :  New  York  Medical  Journal,  September,  1893. 


EROSIONS   OF   THE    STOMACH,  247 

ment  with  intragastric  galvanization,  alternately  ap- 
plying the  spray  or  the  galvanization.  The  reason 
for  the  use  of  galvanization  in  these  cases  lies  in  the 
fact  that  I  had  such  effective  results  in  two  other  cases 
of  probable  erosions  of  the  stomach,  complicated  with 
heart  trouble,"  by  means  of  galvanization  alone.  The 
methodical  application  of  intragastric  galvanization 
combined  with  the  spray  seems  to  increase  the  curative 
effect. 

As  to  diet,  there  is  no  need  for  being  very  rigorous 
in  these  cases.  Frequent  meals,  avoiding  heavy 
vegetables,  salads,  and  pastries,  is  all  I  ordinarily  re- 
quire. 

Cold  ablutions,  light  gymnastics,  outdoor  life  are 
to  be  warmly  recommended. 

Of  medicaments  condurango  and  nux  vomica  are 
frequently,  and  a  good,  easily  assimilated  iron  prepara- 
tion is  always,  appropriate. 

Although  these  medicaments  may  be  of  value  as 
adjuvants,  we  should  rely,  in  my  opinion,  mainly 
upon  the  local  treatment. 

1  Max  Einhorn  :  New  York  Medical  Journal,  July  8th,  1893. 


OHAPTEE  VIII. 

OKGANIC    DISEASES    WITH    CONSTANT 
LESIONS. — Continued. 

Cancer  of  the  Stomach  (Carcinoma  Ventriculi). 

Definition. — Malignant  epithelial  growth  within  the 
stomach. 

Etiology. — The  stomach  is  more  frequently  affected 
with  cancer  than  any  other  organ  of  the  body.  Vir- 
chow's '  statistics  of  all  the  cancerous  diseases  which 
occurred  in  Wiirzburg  between  1S52  and  1855  give 
for  the  stomach  the  proportion  of  3i.9  per  cent.  Ac- 
cording to  Lebert,"  Willigk,'  and  Brinton/  cancer  of 
the  stomach  comprises  about  one-fourth  of  all  cases  of 
cancer.  Haeberlin  '  found  the  percentage  of  cancer  of 
the  stomach  for  the  years  from  1877  to  1886  to  be  ttl. 
According  to  Wyss,°  the  death-rate  from  this  disease 
is  1.9  per  cent.  This  figure,  however,  is  Hable  to 
many  fluctuations.  Haeberlin  first  pointed  out  the 
very  curious  and  discouraging  fact  that  the  frequency 
of  gastric  cancer  is  steadily  increasing.     This  writer's 

'  Virchow  :  Cited  from  Debove  et  Remond,  I.  c,  p.  297. 

'^  Lebfrt :  "Traite  pratique  des  maladies  cancereuses, "  Paris, 
1851,  p.  97. 

^Willigk:  Prager  Vierteljahresschrift,  vol.  x. ,  3,  1853. 

^W.  Brlnton :  British  and  Foreign  Medico-Chiriirg.  Review, 
January,  1857. 

^Haeberlin:  Deutsch.  Arch.  f.  klin.  Medicin,  1889,  Heft  3  und 
4,  p.  461. 

«  Wyss  :  Blatter  f.  Gesundheitspflege,  Zurich,  1872-74. 


CANCER  OF   THE   STOMACH. 


249 


statistics  for  Switzerland  show  a  death-rate  from 
cancer  of  the  stomach  for  1,000  inhabitants  in  the 
years:  1877,0.61;  1878,0.66;  1879,0.72;  1880,0.77; 
1881,  0.85;  1882,  0.87;  1883,  0.85;  1884,  0.84:;  1885, 
0.90;  1886,  0.99. 

Joseph  D.  Bryant,'  of  New  York,  has  also  lately 
shown  that  cancerous  disease  is  constantly  on  the  in- 
crease. According  to  this  eminent  writer,  the  average 
death-rate  from  cancer  in  New  York  City  during  the 
last  ten  years  is  2.17  per  cent  of  the  total  mortality, 
but  that  of  the  preceding  ten  years  only  1.82  per  cent. 
The  following  table,  given  by  Dr.  Bryant,  is  very  in- 
structive as  bearing  on  the  increase  of  cancer  in  the 
United  States: 


Year. 

Population. 

Total 

deaths. 

Deaths 

from 

cancer. 

Cancer 
deaths  per 
100,000  from 
all  causes. 

Cancer 

deaths 

per  100,000 

living. 

1850 

23,191,876 
31,443,321 
38,558,371 
50,155,783 
62, 622, 250 

323,023 
394,153 
492, 263 
756,893 
875,521 

2,088 

3,672 

6, 224 

13,068 

20,984 

646 

932 

1,264 

1,815 

9  0 

1860 

1870 

11.7 
16  0 

1880 

1890 

26.05 
33  5 

The  frequency  of  gastric  cancer  appears  to  be  dif- 
ferent in  different  countries,  and  it  seems  that  there 
are  some  regions  in  which  it  very  seldom  occurs. 
Haeberlin's  above-mentioned  statistics  for  the  whole 
of  Switzerland  show  a  death-rate  from  cancer  of  the 
stomach  of  3  percent  for  the  northern  cantons,  1.5 
per  cent  for  the  western  cantons,  and  1  per  cent 
for  the  southern  cantons.     Griesinger''  states  that  he 

*  Joseph  D.  Bryant :  Tlie  Wesley  M.  Carpenter  Lecture.  New 
York  Medical  Journal,  May  18th,  1895. 

*  Griesinger  :  Arch,  f .  phys.  Heilkunde,  1854,  p.  528. 


250  DISEASES  OF  THE   STOMACH. 

never  observed  cancer  of  the  stomach  in  Egypt,  and 
Heinemann  '  reports  that  he  saw  only  one  case  in  Vera 
Cruz  in  a  period  of  six  years. 

j^ge,—As  regards  the  age  at  which  gastric  cancer 
occurs,  Brinton  collected  600  cases,  the  ages  of  which 
at  death  averaged  50  years.  The  greater  part  (three- 
quarters,  or  435)  of  these  000  cases  fell  in  the  epoch  of 
life  between  -iO  and  TO.  Arranged  in  decades  of 
years,  the  maximum  number  (tw^o-sevenths,  or  102) 
occurred  between  50  and  00.  Comparing  these  num- 
bers with  the  number  of  persons  living  in  these  decades 
of  life,  an  estimate  of  the  relative  liability  of  the  cor- 
responding ages  to  the  malady  is  obtained.  Brinton 
gives  the  maximum  liability  between  00  and  To.  Up 
to  the  age  of  20,  the  whole  risk  is  less  than  one-fiftieth 
of  what  it  reaches  between  20  and  30.  The  latter 
liability  is  multiplied  in  the  following  decades  of  years 
by  3,  0,  8,  and  10  respectively.  The  maximum  then 
seems  to  sink  to  little  more  than  half  for  the  next  two 
decades,  ending  at  the  extreme  age  of  100.  With  ref- 
erence to  age,  Lebert  gives  the  following  figures  in  his 
statistics:  Under  30  years,  1  per  cent;  30  to  40  years, 
IT. 6  per  cent;  40  to  00,  60. T  per  cent;  00  to  TO,  10.3 
per  cent;  above  TO,  4. 4  percent.  Welch's  statistics 
of  2,0To  cases  of  gastric  cancer  show  the  following 
distribution  for  the  different  ages:  10  to  20,  2;  20  to 
30,  55;  30  to  40,  2T1;  40  to  50,  499;  50  to  60,  620; 
60  to  TO,  428;  TO  to  80,  140. 

According  to  all  these  statistics,  the  maximum  lia- 
bility of  gastric  cancer  lies  between  the  fortieth  and 
sixtieth  year.      It  is  very  rare  before    the    thirtieth 

'Heinemann:  Virch.  Arch.,  vol.  58,  p.  180. 


CANCER   OF   THE    STOMACH.  251 

year.  Both  WilkiDson  and  Wiederlioefer/  however, 
each  mention  a  case  in  which  the  disease  was  con- 
genital. M.  Mathieu ""  has  collected  all  the  cases  of 
gastric  cancer  below  the  thirtieth  year  mentioned  in 
literature,  and  the  number  was  27.  Debove  '  recently 
published  a  case  of  gastric  cancer  in  a  young  man  of 
24  years,  and  I  observed  a  similar  case  in  a  man  of 
27  years  two  years  ago.  In  this  latter  case  the  dis- 
ease was  verified  by  an  operation. 

Sex. — The  influence  of  sex  is  far  more  difficult  to 
estimate  than  that  of  age.  Brinton  mentions  784 
cases,  of  which  440  were  males  and  344  females. 
Fox's  *  tabulation  of  the  statements  of  seven  writers 
shows  that  of  1,303  cases  680  were  males  and  623  fe- 
males. Of  Welch's  2,214  cases,  1,233  were  men  and 
981  women. 

These  figures  show  a  higher  percentage  for  men 
than  women,  but  this  statement  is  not  of  necessity 
absolutely  true,  for  the  larger  percentage  of  cancer 
among  men  may  result  from  the  larger  number  of 
male  patients  treated  in  the  hospitals  from  which 
these  statistics  have  been  obtained. 

Heredity. — Most  writers  concur  that  in  some  fami- 
lies several  members  are  found  to  be  afflicted  with 
cancer,  and  are  inclined  to  attribute  this  fact  to  he- 
redity. Every  physician  has  observed  cases  in  which 
the  father  and  one  or  two  sons  had  been  troubled 
with  cancer.  In  some  instances  there  is  a  history  of 
cancer  in  the  parents,  relating  perhaps  to  some  or- 

'  Cited  from  Eichhorst :  "  Lehrbuch  der  spec.  Path,  und  Therapie. " 

2  Max  Mathieu  :  Gaz.  des  Hopit. ,  1884,  p.  118. 

^Debove:  Societe  med.  des  hopit.,  November,  1889. 

4 Fox  :  "The  Diseases  of  the  Stomach,"  London,  1872,  p.  184. 


252  DISEASES   OF   THE  STOMACH. 

gan  other  than  the  stomach.  Cancer  being  such  a 
frequent  malady,  however,  it  is  quite  difficult  to  state 
whether  these  occasionally  observed  facts  are  sufficient 
to  prove  that  heredity  plays  an  important  part,  or 
whether  it  is  a  mere  coincidence.  Statistical  figures 
on  this  point  are  given  by  Lebert  and  Haeberlin.  The 
former  found  an  hereditary  history  in  7,  the  latter  in  8 
per  cent.  Snow  found  among  1,0T5  cases  of  cancer  in 
different  parts  of  the  body,  176  cases,  or  15.7  per  cent, 
in  which  cancerous  disease  had  existed  in  the  family. 

Cause. — Many  factors  have  been  regarded  as  play- 
ing an  important  part  in  the  origin  of  cancer.  Thus 
a  trauma  in  the  gastric  region  has  frequently  been 
held  responsible  for  a  cancerous  affection.  There  is 
no  doubt  but  that  cases  occur  in  which  a  few  weeks 
previous  to  the  discovery  of  a  tumor  in  the  abdomen 
a  trauma  in  the  affected  region  had  taken  place. 
But  it  would  certainly  be  wrong  in  all  these  cases  to 
attribute  the  neoplasm  to  the  preceding  trauma;  for 
there  are  certainly  some  cases  in  which  the  neojDlasm 
already  existed  before  the  trauma  occurred,  and  in 
which  the  latter  merely  caused  the  patient  to  pay 
more  attention  to  the  injured  region,  and  in  this  way 
led  to  an  earlier  recognition  of  the  tumor.  The  fre- 
quent use  of  cider  and  of  sour  wines  is  said  (Eichhorst 
and  Cloquet)  to  favor  the  formation  of  a  cancer. 
Mental  worry  and  sad  emotions  have,  probably 
wrongly,  been  regarded  as  playing  a  part  in  the  cau- 
sation of  this  affection. 

Brinton  suggested  the  following  explanation  for 
cancer  of  the  cardia  and  pylorus:  The  muscular  fibres 
of  these  two  orifices  are  subjected  to  more  work  (con- 


CANCER   OF   THE    STOMACH.  253 

traction)  than  the  rest  of  the  stomach.  The  connec- 
tive  tissue  enclosed  in  them  is  subject  to  contraction 
and  distention.  All  this  causes  a  more  vivid  nutri- 
tion of  these  parts,  and  may  give  rise  to  proliferatiop 
of  the  glandular  tissue,  forming  a  neoplasm. 

Inflammatory  conditions  of  the  gastric  mucous 
membrane  have  frequently  been  described  as  a  predis- 
posing factor  of  the  disease.  Menetrier '  tried  to  show 
the  connection  between  some  forms  of  chronic  gastri- 
tis (polypi)  and  the  cancer.  I  must,  however,  agree 
with  Ewald  and  Eosenheim  that  there  is  no  reason  to 
believe  that  a  chronic  gastritis  favors  the  development 
of  cancer,  for  in  most  instances  we  can  state  that 
the  cancerous  trouble  developed  more  or  less  suddenly 
without  any  preceding  history  of  a  long-standing  dys- 
peptic trouble.  The  gastritis  found  at  the  autopsy  in 
cases  of  gastric  cancer  is  rather  a  secondary  or  accom- 
panying condition  than  a  primary  factor  in  the  dis- 
ease. Chronic  gastric  ulcers  undoubtedly  belong  to 
the  predisposing  factors.  Several  cases  have  been  de- 
scribed in  which  the  formation  of  a  cancer  on  the  bor- 
der of  a  gastric  ulcer  or  its  scar  could  be  clearly  seen. 
Thus  Hauser'^  has  histologically  demonstrated  the 
transition  of  ulceration  into  carcinomatous  prolifera- 
tion, and  asserts  that  in  one  of  the  cases  examined  by 
him  he  found  not  only  the  secondary  development  of 
carcinoma  in  a  gastric  ulcer  of  very  long  standing, 
but  that  occasionally  a  cancer  may  develop  from  an 
affection  of  the  gastric  glands. 

^  Menetrier:  Arch,  de  physiolog. .  lofevi-.,  1888. 
-  Hauser :    "Das  chronische  Magengeschwtir  und  dessen  Bezie- 
hung  zur  Entwickelung  des  Magencarcinoms, "  Leipzig.  1883. 


254  DISEASES   OP   THE   STOMACH. 

Parasitic  Tlieory. — All  the  etiological  factors  men- 
tioned may  perhaps  give  iis  a  better  understanding  of 
the  development  of  the  carcinoma,  but  do  not  by  any 
means  explain  the  ultimate  cause  of  this  malignant 
affection.  Of  late  the  parasitic  theory  of  infectious 
diseases  has  furthered  the  belief  that  in  cancer  also 
we  may  have  to  deal  with  some  micro-organism. 
Many  recent  investigators  have  made  numerous  stud- 
ies and  experiments  in  order  to  elucidate  this  matter. 
Scheuerlen '  believed  he  had  discovered  a  bacillus,  to 
which  he  ascribed  the  origin  of  cancer.  Later  re- 
searches, however,  have  demonstrated  that  his  asser- 
tions were  wrong.  Coley,^  of  New  York,  and  Em- 
merich/ of  Munich,  have  seen  good  results  in  the 
treatment  of  sarcoma,  and  also  carcinoma,  from  the 
use  of  injections  of  the  blood  serum  of  horses  which 
had  been  treated  by  the  erysipelas  cocci.  This  fact 
speaks  in  favor  of  a  parasitic  origin  of  this  malignant 
growth.  Psorosperms  have  frequently  been  found 
within  the  cancer  cells.  It  is,  however,  not  as  yet  de- 
termined whether  these  bodies  are  real  psorosperms, 
or  dried-up  and  changed  cells.  Hence  we  must  con- 
fess that,  notwithstanding  the  many  researches  into 
the  pathology  of  cancer,  we  are  as  yet  totally  ignorant 
of  its  origin. 

Morbid  Au atomy. — It  was  first  established  by  the 
researches  of  Waldeyer  ^  that  the  cancerous  process 
originates  from  the  glandular  elements  of  the  mucous 

'Scheuerlen:  "VeihancU.  desVer.  f.  innere  Medicin."  Deutsche 
med.  Wochenschr.,  1887,  No.  48. 

^  Coley  :  American  Journal  of  the  Medical  Sciences,  1894. 
^  Emmerich  :  Deutsche  med.  Wochenschrift,  1895. 
*  Waldeyer-  Virch.  Arch.,  Bd.  Iv. ,  p.  54. 


CANCER   OF   THE   STOMACH.  255 

membrane,  its  character  being  chiefly  an  atypical  pro- 
liferation of  the  gastric  follicles.  Hence  the  origin  of 
the  neoplasm  is  in  the  mucosa,  whence  it  penetrates 
the  submucosa,  forming  here  a  more  or  less  large  de- 
posit. Frequently  the  larger  part  of  the  growth  is 
situated  beneath  the  mucosa.  After  a  while  this  ma- 
lignant infiltration  may  attack  the  muscularis,  and 
thereafter  extend  to  the  serosa.  The  spread  of  the 
infiltration,  as  a  rule,  takes  place  along  the  con- 
nective-tissue fibres.  The  neoplasm,  after  having 
reached  a  certain  degree  of  development,  may  partly 
slough,  thereby  giving  rise  to  irregular,  ulcerated 
spots.  This  occurrence  is  most  frequent  in  certain 
forms  of  cancer. 

Cancer  of  the  stomach,  like  that  of  other  organs, 
may  present  the  following  varieties: 

1.  Epithelioma.  The  adeno-carcinoma  or  epitheli- 
oma forms  soft  tumors,  presenting  quite  marked  nod- 
ules and  sloughing  very  slowly.  It  consists  of  pseudo- 
glandular  tubuli,  surrounded  by  connective  tissue 
and  infiltrated  with  white  blood  corpuscles.  These 
nodules  show  no  regularity  and  have  no  outlets. 

In  the  early  stage  the  cylindrical  epithelium  is  dis- 
tinguishable, but  as  the  growth  gets  older  the  regular 
arrangement  of  the  epithelium  is  lost  and  the  tubular 
spaces  become  filled  with  cells,  the  product  of  the  mul- 
tiplication of  the  epithelial  cells.  The  latter  undergo 
various  forms  of  degeneration,  and  may  form  small 
cysts  containing  granular  material  and  liquid. 

2.  Medullary  carcinoma.  The  medullary  carcino- 
ma is  characterized  by  large,  flat,  soft,  fungating 
masses,  projecting  above  the  mucous  membrane.     The 


256  DISEASES   OF   THE   STOMACH. 

growth  possesses  very  little  connective-tissue  stroma, 
but  is  rich  in  vessels  and  cells.  It  is  spongy  and  pre- 
sents on  section  a  whitish -yellow  color,  resembling 
brain  matter  in  color  and  consistence.  This  form  of 
growth  is  liable  to  produce  frequent  hemorrhages  (in 
case  the  tumor  looks  blackish  in  consequence  of  blood 
pigment,  it  is  called  "melanotic"),  and  very  often  de- 
generates, forming  ulcerous  spots  on  the  surface. 
Secondary  metastases  are  very  frequent  complications. 


•'^ 


I  , 

I 


''i&M  'HM'^m^^^\^^&^^\'^^^^ 


Fig.  45.— Section  of  Carcinoma  Ventriculi  (Mrs.  J.),  scirrhus  form,    x  140. 

3.  Scirrhus  (carcinoma  simplex  or  fibrosum).  The 
scirrhus  is  characterized  by  the  abundance  of  connec- 
tive tissue.  The  stroma  is  encircled  by  dense  connec- 
tive-tissue fibres,  and  contains  relatively  few  cells. 
The  growth  has  a  firm  and  compact  structure.  It 
does  not  cut  easily,  and  on  section  presents  an  almost 
cartilaginous  tissue  of  a  white-grayish  yellow  color, 
with  yellow  or  red  spots  scattered  all  around.  This 
growth  shows  little  tendency  to  ulceration  in  its  early 


CANCER  OF  THE  STOMACH. 


257 


stages,  but  when  older  it  is  frequently  found  superfi- 
cially ulcerated.  There  is  but  little  tendency  to  sec- 
ondar}^  metastasis. 

4.  Colloid  carcinoma.  The  cells  of  the  alveoli  of 
the  first-described  two  forms  of  cancer  may  undergo 
a  colloid  or  mucous  degeneration.  The  whole  growth 
then  assumes  a  gelatinous  appearance.     Thus  arises 


Fig.  46.— Cross-Sectiou  of  Carcinoma  Ventriculi  (S.),  showing  cancer  cells  infiltrat- 
ing the  connective  tissue.    Small  area  of  inflammation  in  centre.     X  140. 

the  colloid  carcinoma.  Its  appearance  is  very  charac- 
teristic: the  stroma  of  the  tumor  surrounds  transpa- 
rent, gelatinous-looking  masses,  which  consist  of  the 
cancer  cells  in  a  condition  of  colloid  degeneration. 
On  cutting  and  scrajDing,  a  true  cancer  juice  does  not 
exude,  but,  instead,  gelatinous  fragments. 

The  above-described  forms  of  cancer  are  not  always 
typically  characterized,  but  different  forms  may  some- 

17 


258  DISEASES   OF   THE   STOMACH. 

times  be  found  in  one  and  the  same  growth.  At 
times,  again,  the  form  of  the  growth  changes  from 
one  to  the  other  of  the  just-named  varieties  of  cancer. 
The  scirrhus  is  by  far  the  most  common.  Out  of  ISO 
cases  of  cancer  Brinton  found  130  belonging  to  this 
variety  (73  per  cent) ;  32  were  medullary  cancer,  14 
colloid,  3  melanotic,  and  1  epithelioma. 

Topographical  Relations  of  Cancer  of  the  Stom- 
ach.— Size.' — As  regards  size,  two  varieties  of  tumors 
may  be  distinguished.  One  is  characterized  by  grow- 
ing very  little  above  the  surface  and  involving  large 
areas  of  mucous  membrane.  The  other  extends  onl}' 
over  a  small  portion  of  the  mucosa,  and  may  develop 
extensively  in  thickness.  The  first  form  of  tumors 
belongs  to  the  medullary  or  colloid  type,  and  is  not 
met  with  very  frequently.  These  growths  present  a 
flattened  surface,  covered  with  rough,  nodular  masses. 
Blood  extravasations  and  adhesions  to  the  neighboring 
organs  are  of  frequent  occurrence.  The  second  form 
belongs  to  the  scirrhus  variety.  The  tumor  involves 
a  small  circumscribed  portion  of  the  stomach,  and 
tends  to  grow  in  depth  and  height. 

Localization. — The  development  of  cancer  with- 
in the  stomach  may  take  place  at  various  situations, 
at  its  orifices  (cardia  or  pylorus),  or  within  the  organ 
itself.  The  recognition  of  the  localization  of  the  can- 
cer is  much  more  important  than  the  distinction  of 
the  various  forms,  because  each  of  the  three  different 
localizations  of  the  cancer  is  accompanied  by  a  char- 
acteristic train  of  symptoms,  making  its  recognition 
possible  during  life,  and  requiring  a  special  plan  of 
treatment.     As  regards  the  frequency  with  which  the 


CAXCEE  OF  THE  STOMACH.  259 

different  regions  of  the  stomach  are  affected  by  can- 
cer, Brinton  found  the  following  relation :  Out  of  360 
cases  the  pyloras  was  affected  in  219  instances,  a  pro- 
portion of  exactly  60  per  cent;  36  cases  were  cancer 
of  the  cardia,  a  proportion  amounting  to  exactly  10 
per  cent;  in  the  remaining  30  per  cent  the  lesion  was 
scattered  over  the  greater  and  lesser  curvatures.  The 
fundus  is  attacked  least  frequently  of  all :  among 
1,300  cases  of  cancer  of  the  stomach  reported  by 
Welch,  only  19  were  situated  in  the  fundus.  The 
figures  given  by  Lebert,'  Katzenellenbogen,"  and  other 
writers,  agree  very  closely  with  Brinton 's  figures.  It 
is  easily  seen  that  the  localization  of  the  cancer  is  very 
markedly  different  from  that  of  ulcer,  for  in  the  lat- 
ter affection  the  orifices  of  the  stomach  are  the  least 
frequently  affected. 

The  Shape  of  the  Stomach. — The  different  situations 
of  the  cancer  influence  the  shape  and  the  position  of 
the  stomach.  The  organ  is  found  to  be  retracted  and 
small  in  size  in  all  cases  of  cancer  of  the  oesophagus 
and  cardia.  The  viscus  is  very  much  dilated  in  cases 
of  cancer  of  the  pylorus.  The  shape  of  the  stomach 
may  be  distorted  in  case  the  tumor,  situated  near  the 
pyloric  orifice,  descends  by  reason  of  its  weight  and 
drags  the  organ  down  into  the  pelvis.  Distortions 
and  contractions  of  the  stomach  may  also  be  developed 
as  a  consequence  of  inflammatory  adhesions  with  ad- 
jacent viscera. 


*  Lebert :  "Traite  pratique  des  maladies  cancereuses, "  Paris, 
1851,  p.  97. 

2  Katzenellenbogen :  "Beitrage  zur  Statistik  des  Magencarci- 
noms. "     Inaug.  Diss.,  Jena,  1878. 


260  DISEASES   OP   THE   STOMACH. 

Gastric  cancer  is  almost  always  primary,  and  sec- 
ondary growths  of  the  stomach  must  be  considered 
as  a  great  rarity.  Cancer  of  the  stomach  may,  how- 
ever, coexist  with  a  primary  cancer  of  some  other  or- 
gan, as,  for  instance,  the  uterus  and  ovaries.  Ewald 
mentions  a  case  in  which  he  found  an  immense  cysto- 
sarcoma  of  the  uterus  and  a  carcinomatous  infiltration 
of  the  pylorus. 

Secondary  Changes  Accompanying  Cancer  of  the 
Stomach. — Aside  from  the  cancerous  lesions,  the  af- 
fected area  of  the  stomach  is  usually  the  seat  of  vari- 
ous anatomical  changes.  Thus  thickening  of  the 
mucosa,  caused  by  hypertrophy  of  the  connective 
tissue  and  muscular  fibres,  is  frequently  observed. 
Ewald  first  observed  that  the  whole  mucosa  may  pre- 
sent characteristic  lesions  of  chronic  gastritis.  At 
some  places  the  glands  have  disappeared ;  at  others 
they  exhibit  mucoid  changes;  while  at  still  others 
cysts  are  found. 

Cancerous  Metastases. — Secondary  cancerous  de- 
posits in  other  organs  are  of  frequent  occurrence  in 
cancer  of  the  stomach.  Out  of  437  cases  Brinton  saw 
this  complaint  in  210,  or  in  48  per  cent.  The  medul- 
lary and  colloid  forms  of  cancer  are  more  often  asso- 
ciated with  secondary  cancer  than  is  the  scirrhous  form. 
Among  the  organs  in  which  the  secondary  cancer- 
ous deposits  appear,  the  liver  takes  the  first  place. 
Brinton  gives  the  figure  of  secondary  deposits  in  the 
liver  as  25  per  cent  of  all  cases  of  gastric  cancer, 
while  Lebert  gives  the  figure  of  metastasis  in  the 
liver  as  40.9  per  cent  of  all  the  metastases.  This 
writer  gives  the  following  figures  for  the  metastases 


CANCER   OF   THE   STOMACH.  261 

in  other  organs:  peritoneum,  37.5  per  cent;  lungs, 
8.3  per  cent;  ovaries,  4.5  per  cent.  In  some  cases, 
however,  the  secondary  cancer  of  the  liver  is  associ- 
ated with  deposits  in  the  other  organs;  for  instance, 
the  peritoneum,  pancreas,  kidneys.  The  intestines 
and  lungs  may  be  affected  at  the  same  time.  The 
metastatic  infection  usually  takes  place  by  way  of 
the  blood  current  or  the  lymph  vessels.  In  some  in- 
stances, however,  a  direct  extension  in  continuity  of 
the  cancerous  growth  to  a  neighboring  organ  may 
take  place.  Thus  the  extension  of  a  pyloric  cancer  to 
the  liver  or  the  gall  bladder,  or  of  a  cancer  situated 
at  the  greater  curvature  to  the  colon,  or,  again,  of  a 
cancer  of  the  smaller  curvature  to  the  pylorus,  is 
often  observed. 

The  lymphatic  glands  are  frequently  found  swollen, 
but  in  cancer  of  the  stomach  this  symptom  does  not 
appear  as  often  as  in  neoplasm  in  other  organs.  Brin- 
ton  has  observed  this  symptom  in  23.5  per  cent  of 
these  cases.  The  swelling  of  the  glands  is  frequently 
caused  by  cancerous  deposits  in  them ;  sometimes, 
however,  they  may  be  swollen  simply  in  consequence 
of  a  condition  of  irritation. 

The  cancerous  deposits  may  appear  at  one  spot, 
forming  a  new  tumor  varying  in  size  in  the  respective 
organs;  sometimes,  especially  if  the  cancerous  ma- 
terial has  been  carried  through  the  lymphatics, 
numerous  small  deposits  may  exist,  and  the  whole 
organ  may  then  appear  as  if  studded  with  mili- 
ary tubercles.  This  condition  is  frequently  found  in 
the  pleura.  It  is  at  first  quite  difficult  to  decide  at 
one  glance  the  real  nature  of  this  tubercle-like  de- 


202  DISEASES   OF  THE   STOMACH. 

posit.  The  microscope  will  quickly  solve  the  problem. 
Koch's  bacillus  is  found  in  the  real  tubercles,  while 
the  cancerous  deposits  contain  no  bacilli  and  will  show 
the  characteristic  structure  of  the  neoplasm.  While 
the  cancerous  deposits  may  at  times  appear  in  this 
form,  simulating  a  tuberculous  affection,  the  latter 
condition  may  occur  independently  in  cases  of  cancer 
of  the  stomach;  that  is  to  say,  both  affections,  viz., 
cancer  and  tuberculosis,  may  coexist  in  the  same  per- 
son. 

Symptomatology . — In  a  typical  case  the  course  of 
the  disease  is  as  follows:  A  person,  usually  of  middle 
age,  who  has  been  previously  in  good  health,  experi- 
ences uncomfortable  sensations  after  meals,  impair- 
ment of  appetite,  more  or  less  disturbance  of  sleep, 
and  loss  of  strength.  Although  slight  at  first,  these 
symptoms  persist  and  remain  obstinate  to  all  methods 
of  treatment.  In  the  course  of  time  they  become 
more  and  more  aggravated.  Pains  apjjear,  which 
are  always  very  annoying  and  sometimes  show 
exacerbations  of  a  very  acute  and  intense  form. 
While  at  first  there  is  only  belching  and  a  mouthful 
of  food  is  occasionally  ejected,  after  a  while  vomiting 
appears  and  deprives  the  patient  of  the  little  nourish- 
ment he  takes.  Still  later  hemorrhages  appear.  Al- 
though the  quantity  of  blood  ejected  is,  as  a  rule,  not 
large,  this  symptom,  however,  greatly  debilitates  the 
patient,  as  it  usually  occurs  several  times  in  succes- 
sion. About  the  same  time  that  the  hemorrhage  be- 
gins to  appear,  a  tumor  becomes  perceptible  in  the 
gastric  region.  The  patient  now  presents  a  cachectic 
appearance  and  falls  off  daily.     He  becomes  extremely 


CANCER   OF   THE   STOMACH.  26 o 

weak  and  prostrated,  and  usually  death  from  inani- 
tion follows. 

In  analyzing  the  symptoms  accompanying  a  neo- 
plasm of  the  stomach,  it  is  important  to  divide  them 
into:  A,  Those  caused  by  the  growth  itself  (general 
symptoms) ;  and  B,  those  produced  by  the  position  of 
the  growth — (a)  cardia;  (6)  pylorus;  (c)  stomach 
proper. 

A.  General  Symptoms. — These  are  partly  subjective, 
partly  objective,  and  may  be  enumerated  as  follows: 

1.  Anorexia,  or  loss  of  appetite,  is  a  very  frequent 
although  not  very  characteristic  symptom  of  gastric 
cancer.  JSTumerically  Brinton  found  it  present  in 
eighty-five  per  cent.  The  appearance  of  this  symp- 
tom is  sometimes  delayed  until  a  comparatively  late 
period.  Anorexia  in  this  instance  is  not  caused  by 
any  fear  of  pain  the  ingested  food  may  invoke,  but  is 
attributable  to  a  direct  lesion  of  the  nerve  centre  of 
hunger^  There  is  a  real  loss  of  apjDetite,  or  no  desire, 
no  inclination  to  take  food.  In  some  instances  there 
exists  an  actual  aversion  for  food,  especially  with  ref- 
erence to  all  kinds  of  meat  and  food  rich  in  albumin. 
Sometimes  there  is  present  in  these  cases  a  craving 
for  highly  seasoned  articles,  such  as  pickles,  herring, 
and  so  on. 

2.  Pain. — Pain  is  the  most  constant  of  all  symp- 
toms. It  is  present,  according  to  Brinton,  in  about 
ninety-two  per  cent,  and  according  to  Katzenellen- 
bogen  in  a  still  larger  percentage  of  cases.  The  situ- 
ation of  the  pain  does  not  always  correspond  to  the 
site  of  the  lesion.  Thus  a  pyloric  cancer  may  cause 
pains  referable  not  only  to  the  right  hypochondrium, 


264  DISEASES  OF  THE  STOMACH. 

but  also  to  the  sterDiim  or  the  left  hypochondrium. 
The  pain  most  characteristic  of  this  condition  is  usu- 
ally of  a  lancinating  character.  It  begins  at  a  com- 
paratively early  date,  and  soon  assumes  a  marked  se- 
verity. Often  it  becomes  so  intense  that  all  other 
symptoms  are  relegated  to  the  background.  It  is 
characteristic  of  the  pain  of  gastric  cancer  that  it 
never  entirely  disappears.  There  may  be  remissions 
in  the  severity  of  the  pain,  but  there  are  never  really 
free  periods.  Unlike  the  pain  of  gastric  ulcer,  it  is 
either  little  or  not  at  all  affected  by  the  ingestion  of 
food.  Never  is  it  relieved  at  the  end  of  gastric  diges- 
tion or  after  vomiting.  The  character  of  the  pain  is 
sometimes  described  by  the  patients  as  dull,  gnawing, 
or  burning;  sometimes  as  being  attended  by  a  sense 
of  weight,  oppression,  tightness,  or  distention  in  the 
epigastrium;  sometimes,  again,  by  soreness  or  ten- 
derness to  pressure  in  this  region.  Exacerbations  of 
the  pains  are  frequently  caused  by  ulcerative  processes 
taking  place  on  the  surface  of  the  cancer;  some- 
times, again,  by  inflammatory  adhesive  processes 
with  the  neighboring  organs. 

3.  Vomit  in  fj. — Youjiting  is  likewise  one  of  the  most 
frequent  symptoms.  Brinton  found  it  present  in 
eighty-seven  and  one-ninth  per  cent  of  his  cases,  and 
Arnold  in  eighty-six  per  cent.  The  frequency  of  this 
symptom  is  largely  dependent  upon  the  situation  of 
the  cancer,  occurring  much  oftener  in  those  cases  in 
which  the  cancer  occupies  either  the  pylorus  or  the 
cardia.  But  it  may  exist  even  when  the  cancer  has 
no  connection  whatever  with  the  orifices  of  the  stom- 
ach.    The  vomiting  takes  place  either  sometimes  af- 


CANCER  OF   THE   STOMACH.  265 

ter  the  ingestion  of  food  or  independent  of  it.  Thus 
some  patients  vomit  in  the  morning  when  arising, 
and  eject  either  a  quantity  of  mucus  or,  more  fre- 
quently, some  undigested  and  decomposed  food  parti- 
cles. The  ejected  matter  often  has  an  offensive  smell, 
and  as  a  rule  contains  numerous  micro-organisms, 
sarcinae,  yeast  cells,  and  sometimes  changed  blood. 

4.  Hemorrhage. — Vomiting  of  blood  is  observed, 
according  to  Brinton,  in  about  forty-two  per  cent  of 
the  cases  of  gastric  cancer.  The  blood  is  sometimes 
ejected  in  sufficiently  large  quantity  to  be  recognized 
with  the  naked  eye.  More  frequently,  however,  it  is 
not  vomited  in  the  pure  state,  but  mixed  with  gastric 
juice,  food,  mucus;  sometimes  the  blood  has  under- 
gone many  changes  during  its  sojourn  in  the  stomach, 
and  then  looks  blackish,  brownish,  or  jDresents  a  coffee- 
ground  appearance.  The  quantity  of  blood  ejected  is, 
as  a  rule,  smaller  in  gastric  cancer  than  in  ulcer ;  but 
while  in  ulcer  the  hemorrhage  if  once  entirely  arrested 
very  seldom  recurs,  it  is  quite  different  in  cancer. 
For  here  small  hemorrhages  appear  in  succession  for 
a  long  time,  at  intervals  of  a  few  days'  duration. 
Melsena  (blood  in  the  stool)  sometimes  accompanies 
the  hemorrhage.  It  is  found,  however,  less  fre- 
quently than  in  gastric  ulcer.  The  hemorrhage,  as  a 
rule,  takes  its  origin  from  the  minute  vessels  of  the 
submucous  plexuses  or  from  the  capillaries  of  the  su- 
perficial layer  of  the  mucosa  covering  the  neoplasm. 
It  is  very  seldom  that  a  larger  vessel  is  opened,  and  in 
that  case  a  fatal  issue  results.  The  hemorrhage  is 
also  caused  by  manifold  processes  of  ulceration,  in- 
volving the  vessels  of  the  cancerous  mass. 


2G6  DISEASES   OF   THE   STOMACH. 

5.  Tumor. — The  presence  of  a  tumor  in  the  gastric 
region  is  one  of  the  most  reliable  and  pathognomonic 
signs  of  cancer.  The  recognition  of  this  will  depend 
upon  its  size, and  position.  The  larger  the  tumor,  the 
more  superficially  it  is  situated,  the  more  easily  can  it 
be  detected.  Inspection  alone  sometimes  suffices  to 
make  us  suspect  a  malignant  growth:  on  looking  at 
the  gastric  region,  either  in  the  standing  or  recumbent 
position  of  the  patient,  a  protrusion  is  noticed,  either 
below  the  ensiform  process  or  at  the  margin  of  the 
ribs  on  the  right  or  left  side.  The  result  of  inspection 
must  always  be  corroborated  by  the  palpation  method. 
The  latter  is  much  more  reliable  and  by  far  more  effec- 
tive. The  palpating  fingers  encounter  a  resistant 
body  of  varied  size  and  shape,  often  presenting  the 
appearance  of  a  hard,  irregular,  nodulated  mass; 
sometimes,  however,  being  smooth  and  small,  and 
but  slightly  different  from  a  contracted  abdominal 
muscle.  The  latter  cases  are  the  most  difficult  to  rec- 
ognize, and  sometimes  a  positive  diagnosis  as  to  the 
presence  of  a  tumor  can  hardly  be  made.  Percussion 
is  another  means  of  verifying  the  results  of  palpation. 
The  presence  of  a  tumor  in  the  stomach  will  give  a 
dull  sound  on  gentle  percussion,  and  sometimes  a  tym- 
panitic note  on  firm  percussion. 

Whether  the  existing  tumor  belongs  to  the  stom- 
ach or  not,  and  also  what  region  of  the  organ  it 
occupies,  can  be  determined  by  the  following  meth- 
ods: A  tumor  of  the  lesser  curvature  moves  slightly 
downward  on  deep  inspiration,  and  becomes  less  dis- 
tinct or  sometimes  disappears  on  deep  expiration.  On 
inflating  the  stomach  with  carbonic-acid  gas  or  with 


CANCER   OP   THE   STOMACH.  267 

air,  the  resistance  will  be  found  just  above  the  gastric 
area.  Tumors  of  the  pylorus,  if  not  adherent  to  the 
liver,  will  move  down  on  inspiration,  and  if  held  in 
this  position  with  the  hand  will  not  ascend  during 
expiration;  if  adherent  to  the  liver  they  will  move 
up  during  the  act  of  respiration.  A  tumor  of  the 
pylorus  sometimes  disappears  when  the  stomach  is 
full,  on  account  of  the  different  positions  the  stomach 
occupies  in  its  empty  and  in  its  filled  states.  A  tumor 
of  the  greater  curvature  will  move  up  and  down  dur- 
ing inspiration  and  expiration,  and  will  also  descend 
when  the  stomach  is  inflated  with  air;  it  will  then 
occupy  the  lowest  border  of  the  inflated  area. 

According  to  my  experience,  transillumination  of 
the  stomach  gives  the  best  results  with  regard  to  the 
recognition  of  the  presence  of  tumors  and  the  deter- 
mination of  their  situation.  The  tumor,  not  being 
translucent,  is  visible  as  a  dark  spot  within  the  red 
transilluminated  zone  of  the  abdominal  wall.  It  ap- 
pears on  top  of  this  zone  when  the  tumor  occupies 
the  lesser  curvature,  and  at  the  base  of  the  transil- 
luminated area  when  it  springs  from  the  greater  cur- 
vature. The  dark  spot  is  at  the  right  in  tumors  of 
the  pylorus.  In  some  instances  transillumination  dis- 
closes the  presence  of  a  tumor  even  when  the  latter  is 
not  yet  accessible  to  palpation. 

6.  Fever. — The  occurrence  of  fever  in  gastric  can- 
cer does  not  belong  to  the  regular  symptoms.  It  is, 
however,  met  with  oftener  than  is  generally  believed. 
It  usually  appears  in  the  latest  stages  of  the  disease, 
and  is  always  a  bad  omen ;  for  frequently  the  fatal 
issue  is  then  impending.     In  rare  instances  the  rise  of 


268  DISEASES   OF  THE   STOMACH. 

temperature  occurs  at  certain  periods  of  time,  and  pre- 
sents a  marked  similarity  to  a  fever  of  malarial  origin. 
Hampeln  '  relates  a  case  presenting  this  peculiarity. 
In  most  instances  the  fever  does  not  show  any  regu- 
larit}-,  is,  as  a  rule,  not  very  high,  and  accompanied 
by  frequent  intermissions.  The  fever  is  probably  due 
either  to  an  inflammatory  process  w^hich  occurs  in 
the  neighborhood  of  the  neoplasm,  or,  more  fre- 
quently, to  the  absorption  of  a  toxic  material  from 
ulcerated  areas  of  the  tumor.  The  latter  circum- 
stance is  also  responsible  for  a  comatose  condition 
which  is  sometimes  met  in  these  cases,  especially  in 
the  last  stages  of  the  disease. 

7.  Constipation. — More  or  less  obstinate  constipa- 
tion exists  in  the  majority  of  cases  of  gastric  cancer. 
According  to  Ewald,  the  bowels  remain  regular  in 
only  four  to  five  per  cent  of  the  cases.  The  constipa- 
tion may  at  times  alternate  with  diarrhoea;  the  latter 
is  the  result  of  a  catarrhal  condition  of  the  intestinal 
mucous  membrane,  due  to  the  irritation  of  hard 
scybala  or  to  the  products  of  decomposition.  Fre- 
quently diarrhoea  appears  whenever  sloughing  of  the 
neoplasm  occurs.  It  often  indicates  imminent  dan- 
ger, and  is  not  unfrequently  the  proximate  cause  of 
death. 

8.  Cachexia. — Cachexia  is  met  with  in  almost  all 
cases  of  gastric  cancer  after  the  disease  has  progressed 
long  enough,  and  is,  if  present,  an  important  symp- 
tom. Its  absence,  however,  by  no  means  militates 
against  the  existence  of  cancer.  Brinton  regarded 
cachexia  as  pathognomonic  of  cancer,  being  the  re- 

'  P.  Hampeln  :  Zeitschr.  f.  klin.  Med.,  B<1.  8,  p.  232. 


CANCER   OF    THE    STOMACH,  269 

suit  of  a  humoral  disease.  At  present,  however,  most 
writers  agree  that  the  cachexia  is  brought  about  in 
most  instances  not  by  specific  poisons  circulating  in 
the  blood,  but  by  subnutrition.  From  my  own  ex- 
perience, I  can  state  that  I  have  frequently  made 
the  diagnosis  of  gastric  cancer  in  people  who  pre- 
sented a  very  healthy  appearance,  and  who  had  not 
become  emaciated.  The  diagnosis  in  some  of  these 
cases  was  later  verified  either  by  an  operation  or  at  the 
autopsy.  In  one  case  of  cancer  of  the  pylorus  in  a 
man,  forty -two  years  of  age,  who  had  slightly  lost  in 
weight  but  who  was  yet  well  nourished,  in  the  first 
few  weeks  of  treatment  an  increase  in  weight  of  eight 
to  ten  pounds  was  effected.  The  same  patient  was 
operated  upon  some  time  afterward,  the  pylorus  being 
resected,  but  he  succumbed  one  year  later. 

"9.  CEdema. — In  the  first  stages  of  cancer  malleolar 
oedema  sometimes  appears  for  a  short  time.  Boas  * 
found  this  symptom  in  twelve  per  cent  of  his  cases. 
This  oedema  fugax  is,  however,  not  a  pathognomonic 
sign,  as  it  may  occur,  according  to  Boas,  in  other 
affections  of  the  stomach  of  a  non -malignant  type. 
Ascites  or  anasarca,  or  both,  frequently  appear  in  the 
last  stages  of  the  disease. 

10.  Metastases. — As  mentioned  above  in  speaking 
of  pathology,  metastatic  tumors  frequently  occur. 
Thus  enlarged  glands  of  hard  consistence  and  nodu- 
lar character  are  suggestive  of  cancerous  deposits. 
A  nodular  infiltration  of  the  liver,  presenting  a  hard 
and  uneven  surface,  is  very  frequently  met  with  in 

'  Boas  :  "  Spec.  Diagnostik  und  Therapie  der  Magenkrankheiten, " 
3te  Aufl. ,  p.  185. 


270  DISEASES   OF   THE   STOMACH. 

gastric  cancer.  A  carcinomatous  metastasis  in  the 
thorax  is  accompanied  by  the  symptoms  of  pleurisy 
(dulness,  pains,  friction  sound).  Although  these  me- 
tastases, as  a  rule,  appear  quite  late,  still  if  present 
they  may  help  to  clear  the  diagnosis. 

11.  Condition  of  the  Blood. — Laache  '  first  de- 
scribed a  decrease  of  the  number  of  red  blood  cells  in 
this  affection,  while  Haeberlin ""  found  that  the  haemo- 
globin was  greatly  diminished.  According  to  this 
writer,  the  quantity  of  the  latter  is  only  fifty  per  cent 
of  the  normal.  Eisenlohr  '  and  Schneider  *  found  an 
increase  of  the  leucocytes.  While  all  these  conditions 
are  of  some  importance,  as  suggestive  of  cancer,  they 
are  b}'  no  means  specific  and  are  met  with  in  other 
affections. 

Recently  Schneyer  ^  has  stated  that  the  usual  in- 
crease in  the  number  of  leucocytes,  which  is  found 
normally  during  the  period  of  gastric  digestion,  is  ab- 
sent in  all  cases  of  gastric  cancer;  that  is,  the  num- 
ber of  leucocytes  in  the  fasting  condition  and  at  the 
height  of  gastric  digestion  remains  the  same.  This 
symptom  promises  to  be  of  great  value,  and  it  should 
certainl}'  be  further  investigated. 

12.  Condition  of  the  Urine. — Klemperer  ^  and 
Miiller  ^  discovered  that  the  urine  in  cases  of  gastric 
cancer  contains  more  nitrogen  than  the  amount  intro- 
duced with  the    nourishment.      It    has  been   found, 

'  S.  Laaohe  :  "Die  Anamie,"  Christiania,  1883. 

"^  Haeberlin  :  Miinchener  nied.  Wochenschrift,  1888,  No.  22. 

3  Eisenlohr:  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  30,  p.  495. 

^  G.  Schneider :  Inaugural  Dissertation,  Berlin,  1888. 

«  Schneyer:  Zeitschr.  f.  klin.  Med..  1895. 

«G.  Klemperer:  Berl.  klin.  Wochenschr.,  1889,  No.  40. 

'Fr.  Miiller:  Zeitschr.  f.  klin.  Med.,  Bd.  16,  p.  498. 


CANCER    OF   THE    STOMACH.  271 

however,  that  this  symptom  is  not  constantly  pres- 
ent. Besides,  the  elucidation  of  this  fact  necessitates 
quite  complicated  and  laborious  investigations,  v^hich 
can  be  made  only  in  clinics,  but  not  in  private  prac- 
tice. The  amount  of  chlorides  is  frequently  found  di- 
minished, v^hile  the  indigo-forming  substances  are 
often  increased.  Peptonuria  is  occasionally  observed  ; 
it  always  indicates  that  there  is  absorption  from  an 
ulcerated  area  (neoplasm)  within  the  digestive  tract, 
and  is  therefore  of  importance. 

B.  Symptoms  Produced  by  the  Position  of  the 
Growth. — These  may  be  divided  into  three  groups, 
according  to  the  location  of  the  growth. 

{a)  Cardia.  Subjective  Symptoms. — Dysphagia  is 
one  of  the  principal  symptoms  of  cancer  of  the  cardia. 
The  patient  first  notices  that  he  cannot  eat  as  fast  as 
he  would  like.  Frequently  he  has  to  stop  in  the  mid- 
dle of  a  meal,  experiencing  a  sensation  as  if  the  food 
would  not  go  down  into  the  stomach.  This  occurs 
only  if  solid  food  is  taken.  The  patient,  as  a  rule, 
learns  to  help  himself  by  drinking  several  mouthfuls 
of  water  when  such  an  impediment  occurs.  Very  soon 
these  difficulties  Increase  in  severity  and  in  number, 
and  the  patient  can  hardly  partake  of  solid  substances 
without  drinking  liquids  with  them.  Still  later,  the 
patient  finds  it  impossible  to  partake  of  solid  food,  as 
he  cannot  force  it  down  into  the  stomach  even  by 
means  of  water.  Whenever  he  tries  to  do  so,  the  food 
remains  within  the  oesophagus  and  causes  a  feeling 
of  extreme  discomfort  and  oppression.  The  patient  is 
then  usually  obliged  to  eject  it  after  much  straining 
and  retching.     Liquid  food  is  at  this  time  the  only 


272  DISEASES   OP   THE   STOMACH. 

diet;  on  which  the  patient  subsists.  Still  later,  when 
the  stenosis  is  of  a  very  high  degree,  the  patient  is 
unable  to  partake  even  of  a  sufficient  quantity  of  li- 
quids, as  he  can  force  through  the  stenosed  cardia 
only  very  small  amounts  or  none  at  all.  Besides  these 
difficulties  in  eating  and  drinking,  the  patient  often 
complains  of  either  pains  or  a  burning  sensation  at 
the  scrobiculus  and  somewhat  above  it.  "  Vomiting, " 
or,  more  correctly,  ejection,  of  some  mucus  with  or 
without  food  particles  from  the  oesophagus  often  oc- 
curs, especially  at  night,  in  the  recumbent  position 
of  the  patient. 

Objective  Syinptoms. — 1.  Sivallowing  sound.  The 
swallowing  sound,  if  not  absent,  is  frequently  retard- 
ed, and  heard  about  twenty  seconds  after  swallowing 
of  water,  while  normally  it  should  be  heard  after 
seven.  This  sign,  however,  is  not  pathognomonic; 
for,  on  the  one  hand,  I  have  seen  cancer  of  the  cardia 
with  the  appearance  of  the  swallowing  sound  at  the 
normal  time  of  seven  seconds ;  and,  on  the  other  hand, 
I  have  observed  a  case  in  which  there  was  no  organic 
trouble  and  still  the  swallowing  sound  was  not  heard 
for  a  long  time. 

2.  Examinations  with  the  tube.  It  is  best  to  exam- 
ine the  patient  with  silkworm  tubes  of  different  sizes. 
The  examination  should  be  directed  with  the  following 
objects  in  view : 

Permeability. — It  is  of  the  utmost  importance  to 
introduce  the  tube  through  the  oesophagus  into  the 
stomach,  and  to  pay  attention  to  the  fact  whether 
there  be  no  resistance  at  any  place  of  the  passage.  If 
a  resistance  is  felt,  mark  at  what  distance  from  the 


CANCER   OF   THE   STOMACH.  273 

mouth  it  is  situated,  and  also  whether  it  cau  be  over- 
come without  the  appHcation  of  much  force.  Much 
force  should  never  be  exerted ;  if  a  tube  of  a  certain 
thickness  has  met  with  resistance  within  the  oesopha- 
gus, then  try  a  tube  of  thinner  calibre.  In  this  way 
the  degree  of  stenosis  can  be  estimated. 

Particles  of  Tumor. — When  withdrawing  the 
tube  from  the  oesophagus,  it  is  always  necessary  to 
close  the  opening  with  the  thumb,  and  then  empty 
the  contents  into  a  porcelain  dish.  Sometimes  small 
particles  of  the  neoplasm  are  .then  found,  which, 
when  examined  under  the  microscope,  will  frequently 
reveal  the  nature  of  the  trouble,  and  assist  us  in  mak- 
ing a  positive  diagnosis  of  cancer. 

Blood. — The  tube  sometimes  contains  either  fresh 
clear  blood,  not  smelling  badly,  or  blackish-looking 
and  decomposed  blood  mixed  with  mucus,  with  a  very 
disagreeable,  sometimes  fetid  odor.  The  latter  condi- 
tion is  very  frequently  found  in  malignant  strictures 
of  the  cardia,  and  is  sometimes  pathognomonic  of  can- 
cer. Fresh,  clear  blood,  appearing  constantly  at  the 
examination  of  the  tube,  is  suggestive  of  malignant 
trouble  at  the  cardia,  even  when  no  stricture  has  yet 
been  found.  This  symptom,  however,  is  not  a  posi- 
tive one,  as  there  are  other  conditions  that  may  pro- 
duce it.  The  following  case  well  illustrates  the  impor- 
tance of  the  detection  of  blood  at  the  lower  end  of  the 
oesophagus : 

Patient,  about  45  years  old,  had  complained  of  a 
burning  sensation  and  pains  in  the  epigastric  region 
for  over  a  year.  He  had  no  difficulty  whatsoever 
in  the  partaking  of  food.     He  was  not  emaciated  and 

18 


274  DISEASES   OF   THE   STOMACH. 

presented  a  healthy,  good  color.  On  examination, 
the  gastric  region  was  found  to  he  somewhat  tender, 
but  not  painful  to  pressure.  The  outlines  of  the 
stomach  were  not  enlarged.  The  swallowing  sound 
was  heard  seven  seconds  after  the  deglutition  of  wa- 
ter. The  examination  with  the  tube  one  hour  after 
test  breakfast  revealed  no  abnormal  conditions  what- 
ever. The  tube  passed  into  the  stomach  without  the 
slightest  resistance.  The  chemical  analysis  of  the 
gastric  contents  showed  the  presence  of  free  hydro- 
chloric acid,  the  absence  of  lactic  acid,  and  a  degree 
of  acidity  of  60.  On  washing  out  the  stomach  of 
the  patient  in  the  fasting  condition,  it  was  found  that 
it  contained  no  food  from  the  previous  day,  and  the 
water  returned  pretty  clear.  When,  however,  the  wa- 
ter stopped  running  and  the  tube  was  partly  with- 
drawn, so  that  its  end  was  in  the  neighborhood  of 
the  cardia,  a  small  quantity  of  clear  blood,  mixed 
with  some  water,  usually  ran  out.  When  the  upper 
opening  of  the  tube  was  closed  and  the  instrument 
entirely  withdrawn,  it  was  found  to  contain  pretty 
clear  blood.  Numerous  examinations  during  a  j)e- 
riod  of  about  two  months  showed  the  presence  of  the 
same  condition,  especially  with  regard  to  the  appear- 
ance of  blood  at  the  end  of  the  washing  procedure  or 
when  withdrawing  the  tube.  The  characteristic  rest 
treatment  for  ulcer  did  not  benefit  the  patient  in  the 
least.  The  probable  diagnosis  of  cancer  of  the  cardia 
was  made,  and  the  patient  died  one  year  afterward  in 
a  well-known  sanitarium  in  Germany,  in  which  the 
diagnosis  of  cancer  had  been  confirmed. 

3.  Retention  of  Food  within  the  (Esophagus. — In 
most  instances  of  cardiac  stenosis  some  of  the  food 
particles  remain  within  the  oesophagus  above  the  ste- 


CANCER  OF  THE  STOXACH.  275 

nosed  spot.  As  a  rule,  they  become  decomposed  and 
cause  an  irritation  or  inflammation  of  the  oesophageal 
walls.  The  retention  of  food  within  the  oesophagus 
IS  an  important  sign,  and  can  be  discovered  one  hour 
after  the  partaking  of  a  small  meal,  in  the  following 
way:  A  tube  of  ordinary  size  (not  too  narrow)  is 
introduced  into  the  oesophagus  until  about  1  or  2 
cm.  above  the  stenosed  spot,  and  the  patient  ordered 
to  compress  his  thorax  after  a  deep  inspiration. 
As  a  rule,  some  contents  now  appears  through  the 
tube.  The  opening  is  then  closed,  the  tube  withdrawn 
and  emptied,  and  the  obtained  contents  examined  as 
to  appearance  (macroscopical  aspect),  reaction,  whether 
acid  or  not,  whether  containing  lactic  acid,  hydro- 
chloric acid,  or  the  ferments.  A  tube  of  thinner 
calibre  which  can  pass  the  stricture  is  then  taken,  and 
introduced  into  the  stomach. 

By  the  ordinary  expression  method  the  real  gastric 
contents  are  now  obtained.  Their  macroscoj)ical  ap- 
pearance, as  well  as  their  chemical  condition — which 
again  refers  to  acidity,  presence  of  hydrochloric  acids, 
and  ferments — is  compared  with  the  portion  first  ob- 
tained by  means  of  the  thicker  tube.  In  cases  of 
actual  retention  of  food  within  the  oesophagus,  the 
first  portion  shows  the  following  characteristics:  Ee- 
action,  either  neutral,  alkaline,  or  slightly  acid;  hy- 
drochloric acid  and  ferments  absent;  organic  acids 
occasionally  j)resent.  The  particles  of  food  appear  un- 
changed in  any  way  and  are  in  just  the  same  condition 
as  when  swallowed.  The  second  portion,  obtained 
from  the  stomach,  presents  the  appearance  of  chyme, 
shows  a  decided  acid  reaction,  the  presence  of  hydro- 


276  DISEASES  OF   THE   STOMACH. 

chloric  acid  either  in  its  free  state  or  combined,  fre- 
quently the  presence  of  ferments,  especially  rennet, 
and  gives  the  biuret  reaction. 

Ketention  of  food  within  the  oesophagus  is  not  path- 
ognomonic of  cancer  of  the  cardia,  as  it  is  also  found 
in  dilatation  of  the  oesophagus,  caused  either  by  a 
benignant  stricture  of  the  cardia  or  by  a  disturbance 
of  the  peristaltic  action  of  the  oesophagus.  The  latter 
two  conditions,  however,  are  quite  rare,  so  that  the 
symptom  of  retention  is  of  much  importance  in  the 
diagnosis  of  cancer  of  the  cardia. 

4.  The  examination  with  the  oesophagoscope  often 
shows  a  neoplasm. 

(b)  Pylorus.  Subjective  Signs. — Besides  the  pains, 
there  exist  a  decided  feeling  of  fulness  and  quite  fre- 
quent attacks  of  vomiting. 

Objective  Signs. — 1.  Tumor.  A  tumor  can  very 
frequently  be  discovered,  situated  somewhat  to  the 
right  of  the  linea  alba  in  the  area  extending  from  the 
navel  to  the  ribs.  The  methods  of  diagnosing  these 
pyloric  neoplasms  have  already  been  described  above. 
2.  Vomited  matter.  This  consists  of  large  quantities 
of  chyme  (one  to  two  quarts  or  more),  and,  as  a  rule, 
contains  food  which  had  been  taken  a  day  or  two 
before  the  act  of  vomiting.  3.  Ischochymia.  This 
condition  (retention  of  chyme)  is  very  pronounced. 
On  examining  the  stomach  in  the  fasting  condition  of 
the  patient  by  means  of  the  tube  a  considerable  quan- 
tity of  chyme,  containing  more  or  less  decomposed 
food  from  previous  days,  is  found.  Very  frequently 
the  particles  of  food  are  quite  coarse  and  obstruct  the 
openings  of  the  tube.  In  such  instances  it  is  often 
very  difficult  to  empty  the  stomach  entirely,  even  by 


CANCEK   OF   THE   STOMACH.  277 

means    of    washing.     This     object    can     hardly    be 
achieved  in  one  sitting. 

(c)  Stomach  Proper.  Subjective  Symptoms.  —  1. 
Pains.  A  constant  gnawing  pain  in  the  scrobiculus 
cordis  radiating  to  the  back  is  frequently  found  pres- 
ent.    2.   Anorexia  is  very  marked. 

Objective  Symptoms. — 1.  Tumor.  The  presence  of 
a  tumor  situated  to  the  left  of  the  linea  alba  (see  page 
262).  2.  Vomiting  of  small  quantities  of  food,  fre- 
quently presenting  a  blackish  color.  3.  Ischochymia  ^^^^Tttfri 
of  a  slight  degree.  The  examination  by  means  of  the 
tube  of  the  stomach  in  the  fasting  condition  reveals 
the  presence  of  a  small  quantity  of  chyme,  the  parti- 
cles of  food  therein  being  quite  minute. 

Diagnosis. — The  diagnosis  of  cancer  of  the  cardia  is 
made  from  a  study  of  the  above-described  symptoms 
and  the  results  of  the  examination  with  the  tube. 
Cancer  of  the  pylorus  and  stomach  proper  is  diagnosed 
in  the  same  manner.  Although  the  hope  of  finding 
certain  pathognomonic  characteristics  in  the  chemical 
condition  of  the  gastric  contents  with  cancer  of  the 
stomach  has  not  been  realized,  still  the  chemical  an-  . 
alysis  reveals  several  points  which  certainly  aid  in  es- 
tablishing the  diagnosis  of  the  affection  in  question. 
Van  den  Velden,'  in  1879,  first  stated  that  hydrochloric 
acid  is  absent  in  gastric  cancer.  "He  made  use  of  cer- 
tain aniline  dyes  (Congo  and  methyl  violet)  for  the  de- 
tection of  this  acid.  Cahn  and  von  Mering  ^  made  use 
of  an  exact  analytical  method,  and  found  that  in  some 
cases  of  gastric  cancer  the  stomach  contents  revealed 

1  Van  den  Velden :  Arch.  f.  klin.  Med.,  Bd.  22,  p.  369. 
^  Cahn  und  von  Mering  :  Berl.  klin.  Wochenschr.,  1885. 


278  DISEASES   OP   THE   STOMACH. 

considerable  quantities  of  hydrochloric  acid.  Ewald 
justl}'  mentions  in  his  book  that  the  question  as  to  the 
presence  or  absence  of  hydrochloric  acid  in  gastric  can- 
cer had  been  experimentally  broached  as  far  back  as 
1842  by  the  English  physician  Golding  Bird.'  In  a 
man  forty-two  years  old,  with  pyloric  cancer  and  dila- 
tation, this  writer  determined  the  relation  of  hydro- 
chloric and  the  organic  acids  in  a  series  of  examina- 
tions of  the  vomit.  The  results  of  these  examinations 
led  Bird  to  conclude  that  "during  the  most  irritative 
stages  of  the  disease  free  hydrochloric  acid  is  present 
in  the  vomit  in  considerable  quantities,  but  it  gradu- 
ally diminishes  in  proportion  to  the  patient's  loss  of 
strength,  and  that  the  organic  acids  increase  pro- 
portionally as  the  free  hydrochloric  acid  dimin- 
ishes." 

In  forty  cases  of  gastric  cancer  Boas '  found  an  ab- 
sence of  hydrochloric  acid  in  thirty-five,  while  in  the 
remaining  five  free  hydrochloric  acid  was  discovered. 
Among  the  cases  of  gastric  cancer  that  I  have  seen 
during  the  last  few  years,  I  know  of  six  in  which  free 
hydrochloric  acid  was  present,  either  in  normal  or  in 
greater  quantities.  These  cases  of  gastric  cancer  in 
which  hydrochloric  acid  is  found  to  exist  certainly 
lessen  the  value  of  Van  den  A-^elden's  symptom  for 
the  recognition  of  the  disease ;  but  this  symptom  loses 
still  more  in  importance  if  we  consider  that  absence 
of  free  hydrochloric  acid  is  associated  with  many  other 


'  Golding  Bird  :  "  Contributions  to  the  Chemical  Pathology  of 
some  Forms  of  Morbid  Indigestion."  London  Med.  Gazette,  1842, 
p.  391. 

*  Boas  :  I.  c. 


CANCER  OF   THE   STOMACH.  279 

conditions  besides  cancer.  Severe  forms  of  gastric 
catarrh,  and  esi^ecially  achylia  gastrica,  will  undoubt- 
edly furnish  a  greater  contingent  of  cases  with  ab- 
sence of  hydrochloric  acid  than  cancer  of  the  stonaach 
itself. 

Lactic  Acid. — Although  it  was  known  that  the  or- 
ganic acids  are  increased  in  cancer  of  the  stomach, 
and  that  lactic  acid  frequently  occurs,  Boas  '  must  be 
credited  with  laying  stress  upon  the  presence  of  lactic 
acid  in  this  affection ;  he  even  attributed  a  pathogno- 
monic value  to  this  symptom.  According  to  this  in- 
vestigator, lactic  acid,  if  not  introduced  in  a  pre- 
formed state  with  the  food,  but  developing  in  the 
stomach,  occurs  exclusively  in  cancer  of  this  organ. 
After  a  thorough  washing  of  the  stomach,  Boas  gives 
the  patient  a  test  meal,  consisting  of  a  plate  of  barley 
soup.  One  hour  afterward  the  gastric  contents  are 
obtained  and  examined,  either  by  the  Uffelmann  test 
or  by  Boas'  method,  as  to  the  presence  of  lactic  acid. 
This  test  meal  does  not  contain  any  lactic  acid,  and  if 
the  latter  is  found  to  be  present  then  it  must  have 
been  produced  in  the  stomach.  Boas  does  not  deny 
that  there  are  cancers  of  the  stomach  which  do  not 
show  this  symptom.  As  a  rule,  these  are  cases  in 
which  hydrochloric  acid  is  found  to  be  present.  The 
occurrence  of  lactic  acid,  however,  is,  according  to 
Boas,  a  specific  sign.  Many  writers  have  of  late  in- 
vestigated the  question  of  the  appearance  of  this  acid. 
Most  of  them  agree  that  lactic  acid  exists  in  large 
quantities  in  the  majorit}^  of  cases  of  gastric  cancer, 
but  that  it  is  by  no  means  a  specific  sign.     Klem- 

'  J.  Boas:  Deutsche  med.  WocheDschr. ,  1892,  No.  17. 


•280  DISEASES   OF   THE   STOMACH. 

perer,'  Thayer,"  Rosenheim/  and  myself,"  have  pub- 
lished cases  of  non-malignant  gastric  troubles  in 
which  lactic  acid  was  found  in  the  gastric  contents. 

The  absence  of  free  hydrochloric  acid  and  the  pres- 
ence of  lactic  acid,  although  they  are,  as  we  have 
seen,  not  pathognomonic,  are,  however,  of  importance 
and  frequently  help  to  establish  the  correct  diagnosis,  i 

The  diagnosis  of  cancer  can  be  positively  made  un- 
der the  following  conditions : 

1.  If  particles  of  tumor  are  found  {in  the  wash-wa- 
ter or  in  the  tube),  which  under  the  microscope  re- 
veal the  characteristic  picture  of  a  malignant  growth. 

2.  The  presence  of  a  more  or  less  large  tumor  with 
an  uneven  surface,  belonging  to  the  stomach  and  as- 
sociated with  dyspeptic  symptoms. 

3.  The  presence  of  a  tumor  associated  with  fre- 
quent haematemesis. 

4.  Constant  pains,  frequent  vomiting,  ischochymia, 
emaciation — all  these  symptoms  being  quite  perma- 
nent and  not  extending  over  too  long  a  period  of  time 
(six  months  to  one  year). 

5.  Tumor  and  ischoch3"mia. 

6.  Emaciation,  ischochymia,  presence  of  lactic  acid. 

7.  Constant  anorexia  and  pains,  not  yielding  to 
treatment,  accompanied  by  frequent  small  hemor- 
rhages (of  coffee-ground  color). 

Differential  Diagnosis. — In  cases  in  which  a  tu- 
mor exists  it   is   necessary   to   determine  whether  it 

'Kleinperer:  Deutsche  nied.  Woclienschr. ,  1895. 
^  Thayer  :  Johns  Hopkins  Hosp.  Bullet. ,  1893,  No.  31. 
^Rosenheim:  Berl.  klin.  Wochenschr. ,  1894.  No.  39. 
••  Max  Einhoin  :  "  Stenosis  of  the  Pylorus. "     Medical  Eecord,  Jan- 
uary 19tli,  1895. 


CANCER    OF   THE   STOMACH.  281 

originates  from  the  stomach  or  some  other  organ ; 
and  if  it  has  its  seat  in  the  stomach,  whether  it  is 
of  benign  or  malignant  character.  The  first  ques- 
tion, as  to  which  organ  a  tumor  belongs  to,  has  been 
discussed  above.  As  regards  the  second  question, 
we  shall  have  to  differentiate  between  a  tumor 
situated  within  the  stomach  proper  and  one  at  the 
pylorus.  Benign  tumors,  like  fibroma,  myoma,  and 
lipoma '  situated  within  the  stomach,  or  foreign  bodies, 
like  a  gastrolith  or  a  mass  of  hair,  which  may  sim- 
ulate a  neoplasm  are  of  extremely  rare  occurrence 
and  need  hardly  be  taken  into  consideration  when 
making  the  diagnosis.  In  tumors  situated  at  the  py- 
lorus we  meet  much  more  frequently  conditions  of  a 
benign  type,  such  as  cicatricial  thickening  or  simple 
hypertrophy.  The  size  of  the  tumor,  the  condition  of 
its  surface,  whether  smooth  or  nodular,  will  fre- 
quently help  to  decide  this  question.  The  tumor  in 
benign  processes  is  usually  not  very  large  (about  wal- 
nut size),  smooth,  and  does  not  grow;  while  malig- 
nant growths  are  larger,  frequently  present  an  uneven 
surface,  and  increase  in  size.  These  points  are,  how- 
ever, not  enough  to  form  a  decisive  opinion,  and  they 
must  be  supplemented  by  such  data  as  can  be  ob- 
tained. Thus,  long  duration  of  the  sickness — two  or 
three  years  and  rqore — speaks  in  favor  of  a  benign 
process,  while  a  short  duration — six  months  and  so 
on — rather  favors  the  view  of  a  malignant  process. 
In  all  instances   in  which  a  tumor  is   absent  the 


'  Syphilitic  gummatous  tumors  of  the  stomach  also  belong  to  this 
class.  I  have  observed  a  case  of  this  kind  very  recently.  The  \n-es- 
ence  of  other  luetic  manifestations  vrill  remind  us  of  this  possibility. 


28-2  DISEASES   OF   THE   STOMACH. 

differential  diagnosis  of  cancer  will  have  to  exclude 
ulcer,  benign  stenosis  of  the  pylorus  (not  palpable), 
chronic  gastric  catarrh,  achylia  gastrica,  and  very  se- 
vere forms  of  gastric  neurasthenia. 

1.  Ulcer. — In  ulcer  there  is,  as  a  rule,  clear  tongue, 
a  circumscribed  spot  painful  to  pressure,  some  con- 
nection of  the  pains  with  the  period  of  gastric  diges- 
tion, intervals  perfectly  free  from  pain,  very  large 
hemorrhages,  not  recurring  very  frequently,  and,  as  a 
rule,  no  real  anorexia.  In  cancer,  on  the  other  hand,i 
the  tongue  is  almost  always  thickly  furred,  the  pain-| 
ful  area  generally  extends  over  the  greater  part  of 
the  gastric  region,  the  pains  not  having  much  rela- 
tion with  the  digestive  period,  the  hemorrhages  are 
rather  small  and  very  often  recurring,  and  real  an- 
orexia or  aversion  for  food  exists. 

2.  Tlie  benign  stenosis  of  the 2^ylojnis  gives  a  long 
history  of  sickness  interrupted  by  intervals  of  almost 
perfect  euphoria,  extending  over  different  periods  of 
time  (one  year  to  two  or  three  months) ;  the  gastric 
contents  generally  show  the  presence  of  free  hydro- 
chloric acid  and  an  increased  degree  of  acidity.  Ma- 
lignant stenosis  of  the  pylorus  gives  a  short  clinical 
history,  no  intermissions,  and  the  gastric  contents 
most  often  do  not  contain  free  hydrochloric  acid  and 
reveal  the  presence  of  lactic  acid  in  considerable  quan- 
tities. The  degree  of  acidity  is  variable,  sometimes 
being  greatly  increased  through  organic  acids. 

3.  Chronic  Gastric  Catarrh. — A  severe  form  of 
chronic  gastric  catarrh  may  at  the  beginning  give  rise 
to  considerable  difficulty  in  establishing  the  diagnosis 
between  the  two  conditions.     Sometimes  this  will  be 


CANCER   OF   THE   STOMACH.  283 

at  first  impossible.  By  keeping  the  patient  under  ob- 
servation for  a  certain  length  of  time  the  diagnosis 
■will  often  clear  np,  the  chronic  catarrh  will  improve 
under  rational  treatment,  while  cancer  of  the  stomach 
will  either  show  no  amelioration  whatever  or  only  a 
very  slight  one,  the  main  symptoms  of  the  disease  con- 
tinuing in  the  same  way  as  before  the  institution  of 
the  treatment. 

4.  Achylia  Gastrica. — In  achylia  gastrica  the 
tongue  is  sometimes  clear,  the  gastric  contents  show- 
ing no  juice  whatever,  no  mucus,  very  little  fluid  of 
neutral  or  very  slightly  acid  reaction  (acidity,  2  to  6), 
no  ferments,  no  lactic  acid.  The  particles  of  food  are 
very  coarse.  The  stomach  is  empty  in  the  fasting 
condition  of  the  patient;  there  are  no  hemorrhages. 
In  gastric  cancer  the  tongue  is  always  furred,  the  gas- 
tric contents,  as  a  rule,  include  considerable  quantities 
of  mucus,  and  the  degree  of  acidity  is  much  higher, 
even  if  there  is  absence  of  free  hydrochloric  acid. 
The  fragments  of  food  are  not  so  coarse  as  in  the 
former  condition,  lactic  acid  is  frequently  present,  and 
numerous  micro-organisms  are  almost  always  present 
in  the  contents. 

5.  Severe  Form  of  Gastric  Neurasthenia. — A  mis- 
take between  gastric  cancer  and  severe  forms  of  neu- 
rasthenia will  not  occur  frequently.  The  neurotic 
condition  which  can  be  found  in  the  patient,  implicat- 
ing several  other  organs  besides  the  stomach,  will  help 
to  establish  the  true  diagnosis. 

Duration  and  Prognosis. — The  malignant  process 
usually  terminates  fatally  about  one  year  from  the 
commencement   of   the  symptoms.     Cases,   however, 


284  DISEASES   OF   THE   STOMACH. 

are  met  with  in  which  the  disease  runs  a  more 
protracted  course,  eighteen  months  to  two  years. 
On  the  other  hand,  very  acute,  so-called  foudroyant 
cases  are  observed  which  end  in  death  in  from  four 
to  six  weeks.  The  duration  of  the  disease  depends, 
firstly,  upon  the  situation  of  the  neoplasm,  which 
causes  more  disturbances  and  rapid  death  when  oc- 
cupying and  occluding  the  cardiac  or  pyloric  orifice; 
secondly,  upon  the  character  of  the  growths  (some  of 
which,  as,  for  instance,  the  medullary  form,  develop, 
rapidly) ;  and  thirdly,  upon  the  complications  which 
arise  either  from  ulceration  and  hemorrhage  or  from 
cancerous  metastasis. 

The  prognosis  of  cancer  of  the  stomach  is  always 
hopeless.  Oser  justly  said,  the  only  hope  for  the  pa- 
tient can  be  that  the  physician  has  made  a  mistake  in 
the  diagnosis.  No  specific  remedy  has  as  yet  been 
discovered  for  this  ailment,  and  even  surgery  has  not 
been  able  thus  far  to  combat  this  malady  successfully. 

Treatment. — The  treatment  comprises:  A.  Surgical 
interference;  B.  Medical  treatment. 

A.  Surgical  Interference. — Owing  to  the  futility  of 
medicinal  treatment,  surgical  intervention  has  been 
invoked,  and  several  bold  operations  have  been  de- 
vised, which  may  be  resorted  to  in  appropriate  cases. 
These  may  be  divided  into  radical  and  palliative  pro- 
cedures. 

a.  The  radical  operations  mc\\i(\e:  (1)  Resection  of 
the  pylorus;-  (2)  excision  of  the  tumor. 

Billroth'  was  the  first  to  prove  the  possibility  of  ex- 
cision of  the  carcinomatous  pylorus,  in  1878.     Since 

'Billroth.  Wiener  klin.  Wochenschr.,  1891,  No.  34. 


CANCER   OF   THE   STOMACH.  285 

that  time,  distinguished  surgeons  all  over  the  world 
have  been  working  in  this  special  field  of  abdominal 
surgery,  and  have  greatly  contributed  to  the  further 
development  of  this  heroic  method  of  treatment.  The 
aim  in  total  resection  of  the  tumor  is  to  radically  cure 
the  patient,  i.e.,  to  remove  all  the  cancerous  parts  of 
the  organ.  It  will  be  seen  at  a  glance  that  the  indi- 
cations for  this  operation  exist  as  soon  as  a  neoplasm 
accessible  to  the  knife  and  operable  can  be  diagnosed. 
The  earlier  the  diagnosis  is  made  the  better  are  the 
chances  for  radical  interference.  Thus  far  only 
very  few  cases  are  known  in  literature  in  which  the 
excision  of  the  tumor  or  the  resection  of  the  pylorus 
was  followed  by  a  real  cure.  The  reason  that  these 
operative  procedures  have  not  been  so  successful  as 
has  been  expected  is  that  they  are  resorted  to,  as  a 
rule,  too  late.  Gastric  cancer  can  rarely  be  diagnosed 
before  it  has  contracted  adhesions  with  other  organs, 
or  before  metastatic  deposits  have  formed  elsewhere. 
Contraindications  for  these  operations  are:  (1)  If  can- 
cerous metastasis  can  be  discovered  in  other  organs 
(liver,  glands,  etc.);  (2)  adhesions,  i.e.,  if  the  tumor  is 
not  perfectly  movable  and  found  to  be  adherent  to 
other  organs;  (3)  the  large  size  of  the  tumor;  (4)  the 
presence  of  high  degrees  of  anaemia  or  cachexia ;  (5) 
very  old  age. 

h.  Palliative  Operations. — The  palliative  operations 
have  two  purposes  in  view : 

1.  To  permit  of  a  better  introduction  of  food  into 
the  digestive  tract. 

2.  To  remove  as  much   as  possible  the   irritating 
effect  of  food  upon  the  affected  area. 


280  DISEASES   OF   THE   STOMACH. 

The  operations  serving  this  object  are : 

1.  Gastrostomy,  in  malignant  affections  of  the  car- 
diac orifice  or  of  the  oesophagus. 

2.  Gastroenterostomy,  for  mahgnant  affections  of 
the  pylorus  or  its  immediate  neighborhood. 

Gastrostomy  consists  in  establishing  an  opening  be- 
tween the  stomach  and  the  abdominal  wall,  in  order 
to  introduce  food  by  this  new  passage.  The  technique 
of  this  operation  has  lately  been  considerably  im- 
proved, Witzel's  '  method  accomplishing  the  best  re- 
sults. The  indications  for  this  operation  exist  as  soon 
as  dysphagia  is  well  developed  and  the  patient  unable 
to  introduce  large  enough  quantities  of  liquid  and 
semi-liquid  food  through  his  oesophagus  in  order  to 
maintain  his  bodily  weight.  To  wait  until  a  time 
when  even  small  quantities  of  liquid  cannot  pass 
through  the  cardia  into  the  stomach  without  discom- 
fort and  pain  does  not  appear  to  be  advisable,  for  at 
this  period  the  operation,  as  a  rule,  is  more  dangerous 
and  affords  less  relief  to  the  patient.  Contraindica- 
tions for  this  operation  are  the  weakened  condition  of 
the  system,  caused  either  by  advanced  cachexia,  very 
old  age,  or  other  conditions. 

Gastroenterostomy  consists  in  the  establishment  of 
a  new  communication  between  the  stomach  and  the 
small  intestines,  in  this  way  allowing  the  chyme  to 
pass  directly  into  the  small  intestine  without  previ- 
ously passing  through  the  pylorus.  The  indications 
for  this  operation  exist  as  soon  as  the  presence  of  ma- 
lignant trouble  within  the  organ  has  been  diagnosed, 
complicated  with  symptoms  of  ischochymia,  especially 

'  Witzel:  Centralbl.  f.  Chiruig.,  1891,  No.  31. 


CANCER   OF   THE   STOMACH.  287 

if  a  radical  operation  does  not  appear  to  be  feasible. 
The  sooner  it  is  done  the  better.  By  means  of  it  life 
can  be  considerably  prolonged  and  made  much  more 
comfortable  than  is  possible  by  any  other  treatment. 
The  contraindications  are  the  same  as  those  given 
above  under  gastrostomy. 

Exploratory  laparotomy^  v^hich  is  often  performed 
in  this  disease,  seems  to  be  permissible  only  in  those 
cases  in  which  the  diagnosis,  although  not  positive, 
admits  of  the  possibility  of  undertaking  some  kind  of 
an  operation  which  will  afford  either  a  cure  or  at 
least  some  relief  to  the  patient.  To  make  an  explora- 
tory laparotomy  merely  for  the  sake  of  diagnosis  does 
not  seem  to  me  justifiable. 

B.  Medical  Treatment. — The  medical  treatment  has 
the  following  points  in  view :  To  strengthen  the  or- 
ganism by  a  proper  mode  of  nourishment,  thereby 
prolonging  life  as  much  as  possible,  and  to  alleviate 
the  morbid  phenomena.  The  first  point  can  be 
achieved  by  a  proper  diet.  The  more  food  the  patient 
can  be  made  to  take  and  to  assimilate  the  better 
This  should  be  the  most  important  principle  in  guid- 
ing us.  Ample  variety  in  the  bill  of  fare  and  the  in- 
dividual inclination  of  the  patient  will  have  to  be  con- 
sidered. Trousseau  said  that  the  patient  should  be 
allowed  to  eat  what  he  himself  thinks  he  can  best  tol- 
erate. The  following  may  be  given  as  general  rules: 
The  diet  should  consist  of  milk,  kumyss,  matzoon ; 
farinaceous  foods ;  soups  containing  leguminous  foods 
in  a  finely  divided  state  (ground) ;  eggs,  either  raw  or 
soft-boiled,  or  well  beaten  up  in  soup  or  milk ;  small 
quantities  of  meat,   either  raw  and  well  scraped,  or 


288  DISEASES   OF   THE   STOMACH. 

broiled;  the  white  meat  of  a  chicken;  squab,  calf's 
brain,  sweetbreads,  oysters,  lish,  white  French  bread ; 
crackers,  with  the  addition  of  a  small  quantity  of 
sweet  butter;  tea  and  coffee,  wine,  ale.  In  the  later 
stages  of  the  disease  many  articles  of  the  just-de- 
scribed diet  will  not  appear  suitable,  and  the  mainte- 
nance of  nutrition  becomes  gradually  more  difficult. 
Here  the  artificial  foods,  the  various  peptone  prepara- 
tions (Wyeth's  beef  juice,  Kemmerich's  or  Eudisch's 
peptone,  Mosquera's  beef  jelly,  somatose,  Armour's 
beef  peptone),  are  in  place. . 

Medicinal  Treatment. — As  yet  no  specific  remedy 
against  cancer  has  been  found.  The  treatment  must, 
therefore,  be  a  palliative  one,  and  chiefly  directed 
toward  combating  the  more  pronounced  morbid  mani- 
festations and  alleviating  pain.  In  cardiac  strictures 
Boas'  recommends  the  use  of  potassium_iodide.  This 
author  reports  a  case  of  oesophageal  cancer  in  which 
he  employed  sodium  iodide  (2  to  3  gm.  x>'^'0  die)  for 
over  six  months.  During  this  whole  period  the  pa- 
tient remained  free  from  symptoms,  and  even  gained 
nine  pounds  in  weight.  I  have  also  administered 
this  drug  in  several  cases  of  cardiac  stenosis,  and 
frequently  obtained  transient  good  results.  Arsenic 
has  also  been  given  in  this  affection  (solutio  arseni- 
calis  Fowleri,  three  drops  three  times  daily),  some- 
times with  good  results.  One  of  the  principal  reme- 
dies which  is  employed  in  gastric  cancer  is  condurango. 
This  drug  was  recommended  in  1874  by  Friedreich,' 
as  a  specific  against  cancer.     While,  however,  further 

'  Boas  :  I.  c. 

■■^Friedreich:  Berl.  klin.  Wochenschr.,  1874. 


CANCER   OF  THE   STOMACH.  '       289 

researches  did  not  substantiate  this  favorable  report, 
but  rather  proved  that  condurango  has  in  no  v/ay  a 
specific  action  on  cancer,  many  writers  agree  that  it 
is  an  excellent  stomachic  and  as  such  helps  greatly  to 
alleviate  some  of  the  gastric  symptoms  accompanying- 
malignant  affections  of  the  stomach.  Ewald,  Rosen- 
heim, Boas,  strongl}'  advocate  the  use  of  this  drug. 
I  also  administer  it  in  the  greater  number  of  cases. 
Ewald  usually  employs  it  in  combination  with  hydro- 
chloric acid.  Condurango  may  be  given  in  the  form  of  a 
decoction.  25  to  200  gm.  water,  one  tablesi^oonful  every 
four  hours;  or  in  the  form  of  fluid  extract,  of  which 
twenty  drops  or  even  more  can  be  given  three  to  four 
times  daily.  Another  drug  from  which  I  have  some- 
times seen  beneficial  effects  in  this  malady  is  methyl 
blue.  I '  was  the  first  to  recommend  its  internal  use 
in  cases  of  cancer.  I  have  employed  it  in  eight  cases 
of  cancerous  affection  of  either  the  oesophagus  or  the 
stomach.  In  three  of  these  cases  I  was  able  to  note 
a  great  improvement  of  most  of  the  morbid  phenom- 
ena. In  one  case,  in  which  a  considerable  tumor  oc- 
cupied the  gastric  region,  this  appeared  to  have  become 
somewhat  smaller  after  the  drug  had  been  used  for 
about  three  weeks.  This  patient  took  methyl  blue  for 
a  period  covering  eight  to  nine  months  uninterrupt 
edly,  being  all  the  time  quite  free  from  pain  and  not 
losing  in  weight,  the  tumor  meanwhile  not  getting  any 
larger.  After  this  period,  however,  the  tumor  began 
to  grow  again  and  the  patient  rapidly  succumbed. 
Methyl  blue  is  best  given  in  gelatin  capsules,  0.2  gm. 

'Max  Einhorn  :     "Ueber  die   Anwendung  des  Methylenblau. " 
Deutsche  med.  Wocheuschr.,  1891,  No.  18. 
19 


•Z'JU       '  DISEASES   OF   THE   STOMACH. 

once  or  twice  daily.  While  I  do  not  believe  that  this 
drug  is  able  to  cure  a  cancerous  disease  permanently, 
I  am  of  the  opinion  that  it  seems  to  exert  a  beneficial 
action  in  some  cases  of  cancer. 

In  all  cases  in  which  either  decomposition  of  food 
or  ulceration  is  taking  place,  one  of  the  best  reme- , 
dies  to  alleviate  these  conditions,  and  also  subduej 
the  discomforts  produced  by  them,  is  chloral  hydrate.  I 
Ewald  was  the  first  to  advise  its  use,  and  I  also  advo-' 
cate  it  highly.  It  may  be  given  in  the  form  of  a 
three-per-cent  solution,  one  tablespoonful  every  two 
or  three  hours.  The  remainder  of  the  remedies  em- 
ployed is  simply  symptomatic;  thus,  in  case  of  pain, 
opium,  morphine,  or  codeine  must  be  administered. 
The  combination  of  an  opiate  with  belladonna  is  very 
suitable.  If  there  should  be  a  profuse  hemorrhage,  this 
will  have  to  be  treated  similarly  to  that  produced  by 
ulcer.  Obstinate  vomiting  must  be  controlled  either 
by  opiates  or,  in  instances  in  which  vomiting  is  due 
to  stagnation  of  food  in  the  stomach,  by  occasional 
lavage.  Constipation,  which  is  so  frequently  present, 
must  be  relieved,  either  by  mild  aperients  (rhubarb, 
compound  licorice  powder,  cascara  sagrada),  or  by 
enemata,  or  glycerin  suppositories.  Occasionally  the 
following  pills  may  be  prescribed : 

IJ  Extr.  aloes, 

Extr.  rhei  comp., aa2.0 

M.  f.  pil.  No.  XX.     D.     S.  One  to  two  pills  in  the  evening. 


CHAPTER  IX. 

FUNCTIONAL  DISEASES  WITH  VARIABLE 

LESIONS/ 

H  YPEESE  CRETION. 

HypercTilorhydria . 

Synonyms. — Hyperacidity ;  hypersecretion. 

Definition. — The  term  hyperchlorhydria  is  applied 
to  a  condition  in  which  the  gastric  secretion  is  more 
acid  than  normally  and  richer  in  ferments.  Fre- 
quently the  quantity  of  juice  is  also  increased,  hut  it 
is  secreted  only  during  the  period  of  digestion. 

General  Remarks. — ^AVhile  the  older  writers  were 
acquainted,  to  a  certain  extent,  with  digestive  disor- 
ders attended  with  hyperacidity  of  the  gastric  juice, 
it  is  but  quite  recently  that  these  conditions  have  been 
thoroughly  studied  and  placed  on  an  exact  scientific 
basis.  Formerly  it  was  thought  that  in  most  disturb- 
ances of  the  stomach  the  gastric  secretion  was  defi.- 
cient.  Nowadays,  since  the  publications  of  Riegel,"* 
Reichmann,"  Jaworski  and  Glusinski,*  Ewald  ^  and 
others,  we  know  that  in  almost  one-half  of  all  the  pa- 

*  This  heading  comprises  affections  in  which  either  the  secretory 
or  the  motor  function  (prochoresis)  of  the  stomach  is  at  fault,  form- 
ing the  principal  symptoms.  Anatomical  lesions  here  are  not  al- 
■ways  present  and  if  present  are  often  of  various  kinds. 

2  Riegel :  Zeitschr.  f.  klin.  Med. ,  Bd.  11  and  12. 
sReichmann:  Berl.  klin.  Wochenschr. ,  1882,   No.  40;  1884,  No. 
48 ;  1887,  No.  12. 

*  Jaworski:  Zeitschr.  f.  klin.  Med.,  Bd.  11,  Heft  2  und  3. 
^  Ewald  :  I.  c. 


292  DISEASES   OF   THE   STOMACH. 

tients  suffering  with  digestive  disorders  the  gastric 
juice  is  rather  increased. 

According  to  my  own  experience,  the  gastric  disor- 
ders accompanied  with  hyperchlorhydria  form  more 
than  one-half  of  the  number  of  patients  troubled  with 
digestive  affections.  With  reference  to  this  point  the 
following  table,  which  I  published  in  the  Medical 
Record  of  November,  1895,  may  be  of  interest: 

Table   of    Private   Patients    whose   Gastric   Contents   have 
BEEN  Analyzed  During  1889  to  1895. 

T^T      1         ^       .-.•.,,       (    in  89  :  HCl  =  0,  acidity  =    2  to    40 

Number  of  patients  with  hy- \    .    „.    ,,„,       „        .,./        .„  ,      o^ 

11     1     J  •      low  i    m  31 :  HCl  =  0,  acidity  =  40  to    80 

pochloihydria,   187,  •     ]     •     an    Trr-i    i  •^•/         ^K4.       ai\ 

<.    in  67  :  HCl  +.     acidity  =  15  to    40 
Numbei"  of   patients  with  eu-  j 

chlorhydria,  91,        .        .    [    i^  91  :  HCl +,     acidity  =  40  to    60 

Number  of  patients  with  hy-  i 

perchloriydria,  286.         .    \  ^^  ^86  :  HCl  -f ,     acidity  =  60  to  140 

Total  number  of  patients,  564. 

Thus  more  than  one-half  of  the  cases  showed  a  hy- 
peracid state  of  the  gastric  juice. 

Whether  hyperacidity  should  be  considered  as  a  dis- 
ease sui  generis  or  not,  is  difficult  to  decide.  Hyper- 
acidity certainly  describes  only  one  symptom,  show- 
ing that  the  secretory  function  is  increased  without 
pointing  to  any  definite  anatomical  lesion ;  but  this 
symptom  may  be  of  the  greatest  importance,  and  very 
often  covers  the  whole  ground  upon  which  is  based 
the  subjective  suffering  of  the  patient  and  the  ration- 
al treatment  at  our  command.  That  is  the  reason 
why  I  think  it  best  to  discuss  hyperchlorhydria  in  a 
special  chapter. 

Does  hyperchlorhydria  always  give  rise  to  digestive 
disturbances  and  other  symptoms?     In  order  to  an- 


HYPEECHLORHYDRIA.  293 

swer  this  questioD  it  will  be  best  to  determine  more 
exactly  where  hyperchlorhydria  begins — ^.e.,  to  what 
degree  of  acidity  we  may  apply  this  term.  According 
to  the  experience  of  Ewald  and  others,  to  which  I  can 
add  my  own,  the  degree  of  acidity  of  the  gastric  con- 
tents about  an  hour  after  Ewald 's  test  breakfast  va- 
ries, as  a  rule,  in  healthy  people  between  40  and  60. 
A  degree  of  acidity  of  70  and  above  is  therefore  con- 
sidered as  hyperacidity.  The  above  question  will  now 
be  put  in  the  following  way :  Must  people  with  an 
acidity  of  their  gastric  contents  of  TO  and  above  al- 
ways present  morbid  phenomena  '?  To  this  I  must 
answer  in  the  negative.  From  a  very  large  experi- 
ence, I  can  assert  that  we  occasionally  meet  with  per- 
sons whose  degree  of  acidity  of  the  gastric  contents  is 
as  high  as  100  and  even  more,  without  producing  any 
disturbances  whatever.  This  condition  need  not  even 
be  a  transient  one,  but  may  last  for  years  and  still 
cause  no  discomfort.  This,  however,  is  not  the  rule, 
and  the  greater  number  of  persons  with  a  hyperacid 
juice  are  not  free  from  disturbances,  but  rather  pre- 
sent a  ver}^  characteristic  train  of  symptoms.  We 
speak  of  a  pathological  hyperchlorhydria  whenever 
this  condition  is  associated  with  subjective  complaints. 
Etiology. — As  has  been  just  stated,  hyperchlorhy- 
dria is  of  very  frequent  occurrence.  It  is  met  with 
chiefly  in  adults,  although  neither  the  young  nor  the 
old  are  exempt.  In  the  majority  of  cases  its  origin 
may  be  traced  either  to  a  psychological  cause,  such 
as  grief  or  worry,  or  to  mental  overwork.  It  is,  as 
a  rule,  more  frequent  among  the  wealthier  and  more 
educated  class  of  people,  as  lawyers,  bankers,  etc.,  al- 


294  DISEASES   OF   THE   STOMACH. 

though  hyperchlorhydria  may  be  met  with  also  among 
the  poor.  But  in  addition  to  this  so-called  reflex  ac- 
tion of  the  brain  as  an  etiological  factor  of  the  dis- 
ease, there  may  also  be  direct  causes;  thus,  for  in- 
stance, the  habit  of  taking  highly  spiced  dishes,  much 
ice  water,  and  strong  alcoholic  drinks  is  liable  to  pro- 
duce this  trouble. 

Symptomatology. — This  disorder  is  usually  charac- 
terized by  a  gradual  development.  At  first  the  i^a- 
tient  experiences  an  uneasy  sensation  about  two  or 
three  hours  after  dinner.  Later  this  changes  into  a 
feeling  of  distress  in  the  epigastric  region,  occurring 
about  two  hours  after  each  meal,  instead  of  after  din- 
ner alone.  The  pain  lasts  for  an  hour  or  two,  or  even 
three,  and  then  disappears.  Very  often  pyrosis  ac- 
companies the  pain  and  occasionally  regurgitation  or 
water  brash  takes  place.  The  patients,  as  a  rule,  can 
ease  their  pain  by  taking  some  nourishment,  especially 
one  that  is  rich  in  albumin ;  thus  the  white  of  an  egg, 
milk,  or  meat  is  capable  of  dispersing  the  pain.  It 
also  disappears  after  the  ingestion  of  some  alkali,  as 
Vichy  water  or  bicarbonate  of  soda.  The  appetite  is 
ordinarily  not  diminished  but  frequently  rather  in- 
creased. Thirst  is  generally  enhanced.  The  bowels 
in  most  cases  are  constipated. 

The  composition  of  the  food  is  frequently  of  signifi- 
cance with  reference  to  the  character  of  the  pains, 
which  are  less  intense  in  people  partaking  of  large 
quantities  of  meat  and  eggs,  while  they  are  much  more 
severe  in  persons  living  on  a  chiefly  vegetable  diet. 

Besides  the  attacks  of  pain,  patients  affected  with 
hyperchlorhydria  very  often  suffer  from  severe  head- 


HYPEECHLORHYDEIA.  295 

ache  or  attacks  of  dizziness,  which  may  appear  either 
independently  or  accompanied  by  gastric  pains.  The 
patients,  as  a  rule,  do  not  lose  in  weight  except  in 
some  rare  instances,  in  which  a  faulty  and  insufficient 
diet  has  been  maintained  for  quite  a  long  time. 

Objective  Symptoms. — On  palpation  the  gastric  re- 
gion is  frequently  found  tender  on  pressure,  although 
not  actually  painful,  this  tenderness  not  being  limited 
to  one  circumscribed  spot,  but  to  a  larger  area  cover- 
ing the  greater  part  of  the  gastric  region.  The  con- 
tour and  the  size  of  the  stomach  are  frequently  found 
enlarged,  although  this  condition  is  by  no  means  char- 
acteristic of  the  affection  in  question.  A  splashing 
sound  can  be  produced  after  the  ingestion  of  water  or 
after  meals,  but  not  in  the  fasting  condition. 

On  examination  of  the  stomach  with  a  tube  in  the 
fasting  condition  it  is  found  to  be  empty,  or  only  a 
few  cubic  centimetres  (five  to  ten)  of  gastric  juice 
can  be  obtained.  One  hour  after  Ew aid's  test  break- 
fast, or  two  to  four  hours  after  Leube-Eiegel's  test 
dinner,  the  gastric  contents  include  an  abundance  of 
hydrochloric  acid  and  of  the  ferments,  the  acidity  be- 
ing, as  a  rule,  much  higher  than  normally  (twice  or 
three  times  as  high).  A  disc  of  egg  albumen  becomes 
digested  in  the  filtrate  of  these  contents  in  a  very 
short  time  (sometimes  in  half  an  hour).  The  gastric 
contents  obtained  three  to  four  hours  after  the  test 
dinner  show  macroscopically  that  the  meat  has  been 
perfectly  digested,  while  starchy  substances  are  yet 
either  unchanged  or  very  little  altered.  The  filtrate 
of  the  gastric  contents,  either  after  the  test  dinner  or 
after  the  test  breakfast,  will  reveal  the  presence  of 


29G  DISEASES   OF   THE   STOMACH. 

either  starch  or  large  quantities  of  erythrodextrin. 
The  addition  of  a  few  drops  of  Lugol's  solution  to  the 
filtrate  will  produce  either  a  blue  color  or  an  intense 
dark  red. 

The  high  degree  of  acidity  is  most  commonly  caused 
by  free  hydrochloric  acid.  The  difference  between  the 
amount  of  free  hydrochloric  acid  (as  determined  by 
Mintz's  or  Toepfer's  method)  and  the  total  acidity  is  not 
great,  the  figure  very  frequently  being  from  10  to  20. 

The  motor  faculty  of  the  stomach  is  usually  not  im- 
paired ;  in  a  few  instances  it  is  rather  increased. 
Thus  two  hours  after  the  test  breakfast,  or  six  to  sev- 
en hours  after  the  test  dinner,  the  stomach  is  found  to 
be  either  empty  or  to  contain  but  very  little  food.  The 
salol  test  likewise  shows  salicyluric  acid  in  the  urine 
as  early  as  an  hour  after  the  ingestion  of  the  salol. 

The  degree  of  acidity  of  the  urine  is  frequently  di- 
minished during  the  digestive  period.  This,  however, 
is  not  always  the  case,  for  occasionally  the  degree  of 
acidity  of  the  urine  and  of  the  gastric  contents  may 
be  found  increased  at  the  same  time. 

Course. — At  the  beginning  hyperchlorhydria  is 
most  frequently  intermittent.  The  patient  may  suffer 
from  this  affection  for  several  days,  weeks,  or  even 
months,  becoming  free  from  the  ailment  for  periods 
of  time  which  vary  from  several  weeks  to  months  or 
even  years.  After  this  interval  the  trouble  either  re- 
curs spontaneously  without  any  apparent  cause,  or  is 
evoked  by  a  severe  mental  shock  or  worry.  Later  on 
the  periods  of  remission  may  become  shorter,  the  pe- 
riods of  hyperchlorhydria  longer,  and  at  last  this  con- 
dition may  become  permanent. 


HYPERCHLORHYDEIA.  297 

The  following  is  a  typical  case  of  hyperchlorhydria : 

N.  B.  0 ,  '2^  years  old,  complained  for  the  last 

two  and  a  half  years  of  digestive  disturbances  which 
consist  in  pyrosis,  dryness  in  the  throat,  drowsiness, 
and  constipation.  These  symptoms  were  always  pres- 
ent and  became  aggravated  at  certain  periods  of  time. 
Patient  has  never  lost  much  in  weight.  For  the  last 
three  months  patient  suffered  from  pains  in  the  gas- 
tric region.  These  appear  quite  regularly  one  and  a 
half  to  two  hours  after  meals,  and  last  for  one  and  a 
half  to  two  hours.  Before  meals  and  shortly  after- 
ward patient  feels  well.     Appetite  very  good. 

Present  Condition. — Patient  looks  somewhat  pale. 
Tongue  clear,  with  but  a  slight  coating  at  the  back. 
Gastric  region  not  painful  to  pressure;  stomach  not 
enlarged. 

One  hour  after  the  test  breakfast :  HCl  -f- ;  acidity 
=  100;  free  HCl  =  88;  dextrin  +  traces;  erythro- 
dextrin  +  very  much. 

In  the  fasting  condition,  the  stomach  is  empty. 

The  following  represents  an  atypical  case  of  hyper- 
chlorhydria : 

Patient  (M.  A )  has  been  ailing  for  four  or  five 

years  with  pains  in  the  stomach  and  frequent  vomit- 
ing. Sometimes  she  has  no  pains  for  two  to  three 
weeks,  at  the  end  of  which  time  they  reappear.  The 
pains  occur  immediately  after  meals.  She  also  vom- 
its large  quantities  of  food.  On  examination  I  found 
that  the  stomach  was  only  sensitive  to  pressure;  oth- 
erwise nothing  could  be  discovered.  With  regard  to 
diagnosis  it  was  questionable  whether  I  had  to  deal 
with  an  ulcer  or  with  some  functional  disorder  of  the 
stomach.  The  regular  treatment  for  ulcer  (milk  diet, 
rest,  large  doses  of  bismuth)  was  instituted,  but  after 


298  DISEASES   OF   THE   STOMACH. 

a  period  of  three  weeks  the  symptoms  had  not  abated. 
The  pains  appeared  in  the  same  severity  and  the  vom- 
iting persisted.  The  failure  of  the  treatment  made  it 
probable  that  there  was  no  ulcer.  Patient  was  exam- 
ined one  hour  after  a  test  breakfast,  and  the  following 
condition  found:  HC1-|-;  acidity  =  100;  free  HCl  = 
S6.  In  the  fasting  condition  the  stomach  w^as  empty. 
Hyperchlorhydria  was  diagnosed,  and  the  treatment 
arranged  accordingly.  The  patient  now  rallied  very 
quickly  and  recovered  entirely. 

Prognosis. — The  prognosis  in  hyperchlorhydria  is, 
as  a  rule,  quite  good,  except  in  some  cases  of  a  very 
protracted  and  severe  nature,  in  which  the  prognosis 
regarding  the  complete  disappearance  of  this  condi- 
tion is  bad,  although  even  then  there  is  no  danger  of 
a  fatal  issue. 

Diagnosis. — The  diagnosis  of  hyperchlorhydria  is 
made  either  from  the  subjective  symptoms  alone  or 
from  these  in  connection  with  the  results  of  a  chemical 
examination  of  the  gastric  contents.  The  subjective 
symptoms  characteristic  of  hyperchlorhydria  are : 

1.  Pain,  appearing  constantly  about  two  to  three 
hours  after  meals.  Eelief  from  the  pain  is  felt  imme- 
diately after  the  ingestion  of  an  alkali,  or  a  little 
while  after  the  partaking  of  some  food,  especially  al- 
buminous. 

2.  Appetite  and  thirst  are  either  in  a  healthy  condi- 
tion or  increased. 

3.  No  marked  cachexia. 

4.  Constipation. 

Although  all  the  symptoms  mentioned  make  the  di- 
agnosis of  hyperchlorhydria  probable,  it  can  be  made 


HYPERCHLORHYDEIA.  299 

with  certainty  only  after  repeated  examinations  of  the 
gastric  juice. 

1.  On  examination  of  the  stomach  in  the  fasting 
condition,  the  organ  is  either  found  empty,  or  con- 
tains only  a  few  cubic  centimetres  of  juice. 

2.  One  hour  after  Ewald's  test  breakfast  the  degree 
of  acidity  is  found  greatly  increased,  owing  to  the 
large  amount  of  free  hydrochloric  acid. 

Differential  Diagnosis. — In  making  the  diagnosis 
of  hyperchlorhydria,  we  shall  have  to  exclude  all  con- 
ditions which  are  liable  to  give  similar  symptoms;  for 
instance,  gastric  ulcer,  permanent  hypersecretion,  and 
biliary  colic.  The  characteristic  symptoms  of  ulcer 
have  been  described  above,  and  we  shall  here  limit 
ourselves  to  the  remark  that  the  pain  of  an  ulcer, 
even  if  this  is  accompanied  by  hyperchlorhydria,  does 
not  disappear  entirely  after  the  ingestion  of  large 
doses  of  alkalies.  Permanent  hypersecretion  is  very 
frequently  accompanied  by  vomiting,  and  the  most 
intense  attacks  of  gastric  pain  appear,  as  a  rule,  in 
the  middle  of  the  night  or  early  in  the  morning.  On 
examination  with  the  tube,  the  stomach  in  the  fasting 
condition  is  found  to  contain  considerable  quantities 
of  gastric  juice  (80  to  100  c.c).  Biliary  colic,  not  ac- 
companied by  jaundice  or  by  a  considerable  palpable 
swelling  of  the  gall  bladder,  may  give  rise  to  errors  as 
to  the  real  cause  of  the  pain.  In  biliary  colic,  how- 
ever, the  pains,  as  a  rule,  appear  later  than  in  hyper- 
chlorhydria (four  to  five  hours  after  a  meal),  and  are 
not  eased  by  the  ingestion  of  food  or  by  alkalies.  An- 
other means  of  differential  diagnosis  is  that  the  pains 
in  biliary  colic  most  commonly  extend  over  the  right 


300  DISEASES   OF   THE   STOMACH. 

epigastric  and  hypochondriac  regions,  whereas  the 
pains  of  hyperchlorhydria  are  felt  more  in  the  middle 
of  the  epigastrium,  although  sometimes  radiating  far- 
ther to  the  right. 

Treatment. — Hygienic  Regimen. — In  view  of  the 
fact  that  hyperchlorhydria  is  most  frequently  caused 
by  too  much  mental  work,  the  daily  life  of  the  patient 
as  to  amount  of  work,  bodily  exercise,  mental  rest, 
and  pleasure  must  be  regulated.  With  regard  to  this 
point,  the  same  rules  will  not  apply  to  all,  but  it  will 
be  necessary  to  individualize  .each  case  for  itself. 
Thus  business  men  with  a  great  deal  of  responsibility 
resting  upon  them,  lawyers,  politicians,  and  physi- 
cians must  be  sent  away  from  their  work  to  some 
country  place,  so  as  to  relieve  their  brains  temporarily 
from  the  strain.  Ladies  moving  in  high  social  cir- 
cles, and  participating  in  all  manner  of  festivities, 
will  have  to  be  restricted  to  a  more  quiet  life.  Again, 
there  are  people  with  large  fortunes  and  without  any 
occupation  whatever,  who  become  sick  from  paying 
too  much  attention  to  their  own  bodily  functions. 
Here  it  will  be  necessary  to  occupy  the  mind  of  these 
patients  with  some  kind  of  work. 

Cold  sponge  baths  in  the  morning,  bodily  exercise 
of  about  eight  to  ten  minutes'  duration  every  morn- 
ing are  in  most  instances  of  value.  Walking  once  or 
twice  a  day  for  half  an  hour  to  an  hour,  horseback 
riding,  driving,  bicycle  riding  should  be  highly  recom- 
mended. 

Diet. — All  substances  that  are  liable  to  excite  in- 
tensely the  glands  of  the  stomach  must  be  excluded 
from  the  dietary  of  such  patients.     Therefore  all  kinds 


HYPERCHLORHYDRIA.  301 

of  acids,  including  organic  acids  (citric,  tartaric,  ace- 
tic acid) ;  all  kinds  of  spices,  such  as  pepper,  mustard, 
horseradish,  and  the  like,  must  he  forbidden.  The 
food  should  consist  of  material  rich  in  albumin,  while 
the  quantity  of  starchy  substances  should  be  dimin- 
ished. Thus  all  kinds  of  meat  (even  game),  fish, 
oysters,  eggs,  milk,  should  be  taken  in  large  quanti- 
ties. Bread  and  butter  are  permitted.  Potatoes, 
spinach,  asparagus,  green  peas,  farina,  and  rice 
should  be  taken  only  in  small  amounts.  Whiskey 
and  wines  should,  as  a  rule,  be  avoided.  Cacao, 
weak  tea,  weak  coffee,  and  beer  can  be  given  in  mod- 
erate quantities. 

As  a  rule,  it  is  advisable  to  have  the  patient  partake 
of  five  or  six  meals  daily,  three  heavy  and  two  or  three 
lighter  ones.  The  heavier  meals  should  not  deviate 
much  from  the  ordinary  bill  of  fare,  while  the  lighter 
meals  should  consist  either  of  a  glassful  of  milk  or 
matzoon,  with  bread  and  butter  or  a  cup  of  cocoa  and 
a  few  crackers,  or  occasionally  a  cup  of  bouillon  with 
an  egg  beaten  up  in  it,  and  some  bread,  or  half  a 
dozen  oysters,  a  few  crackers,  and  a  glass  of  beer. 
The  patient  must  be  impressed  with  the  importance  of 
thoroughly  masticating  the  food  and  eating  slowly,  be- 
sides resting  fifteen  to  twenty  minutes  after  each  meal. 

Outline  of  Diet  in  Hyperchlorhydria. 

Calories. 

7:  30  A.M.,  two  eggs, 160 

wheaten  bread,  50  gm.,  .         .         .128 

butter,  20  gm., 163 

milk,  250  gm.,      ....         .  169 


3()2 


DISEASES   OF   THE   STOMACH. 


10:  30  A.M.,  matzoon  or  milk,  200  gm., 
crackers  or  bread,  '60  gm., 
butter,  10  gm., 
1  P.M.,  broiled  meat,  100  gm., 

mashed  potatoes,  50  gm.,     . 

bread,  30  gm., 

butter,  10  gm.,     . 

weak  tea  or  Vichy  water,  200  gm 
3:  30  P.M.,  the  same  as  at  10:  30  a.m., 
6:30 


Calories 

.  135 

.  77 

.  81 

.  210 

.  63 

.  77 

.  81 

.  293 


soup  (with  barley  or  vermicelli),  200  gm.,  100 
bread  and  butter  (bread,  30  gm. ;  butter, 

10  gm.), 158 

meat  (broiled  or  cooked),  100  gm.,  .  210 

potatoes,  baked,  50  gm.,         .         .         .60 
green  vegetables  (spinach,  green  peas), 

50  gm., 80 

coffee  (half  milk),  100  gm.,    .         .         .31 
10  P.M.,  oysters  and  crackers,  or  cold  meat  sandwich, 

one  glass  of  beer,         .         .         .         .         .200 

2,519 

Medicamenis. — All  kinds  of  alkalies  can  be  used 
in  the  treatment  of  this  affection.  Where  hyperchlor- 
hydria  is  not  complicated  with  constipation,  bicarbo- 
nate of  soda  may  be  given,  either  alone  or  in  combina- 
tion with  sugar  of  milk  or  peppermint  sugar  (German 
Pharmacopceia),  in  doses  of  half  a  teaspoonful  to 
about  one  teaspoonful  three  times  a  day,  two  hours 
after  meals.  Calcined  magnesia  and  magnesia  am- 
raonio-phosphorica  neutralize  four  times  as  much  acid 
as  bicarbonate  of  soda.  The  following  prescriptions 
are  therefore  very  serviceable : 

I^  Sodii  bicarbon., 

Magnes.  ust. , aa  20.0  3  v. 

M.  exactissime,  f.  pulv.     D.  ad  scatulani.     S.  Half  a  teaspoon 
ful  to  a  teaspoonful  three  times  daih",  two  hours  after  meals. 


HYPEECHLORHYDKIA.  303 

Or, 

I^  Sodii  bicarbon.,        ......        20.0  3  v. 

Magnes.  ust., 

Magnes.  ammoniophospli.,     '.        .        .        aa  10.0  3  iiss. 
M.  exactissime,  f.  pulv.     D.  ad  scatulam.     S.  Half  a  teaspoon- 
ful  to  a  teaspoonfiil  three  times  daily,  two  hours  after  meals. 

In  cases  which  are  accompaDied  by  constipation, 
magnesia  usta  and  some  rhubarb  can  be  added,  and 
here  I  frequently  prescribe  the  following : 

IJ  Magnes.  ust., 

Pulv.  rad.  rhei, aa      7.5     3  ij. 

Sodii  carbon,  exsiccat., 
Sodii  bi carbon., 

Elseosacch.  menth.  pip aa    15.0     3  iv. 

M.  exactissime,  f.  pulv.  D.  ad  scatulam.  S.  Half  a  teaspoon- 
ful  to  a  teaspoonful  three  times  daily,  two  hours  after  meals,  to  be 
taken  in  plain  water  or  in  Vichy  water. 

Bouveret  uses  sodium  bicarbonate  in  2  gm.  doses, 
to  be  taken  two  hours  after  lunch  and  after  supper, 
and  to  be  repeated  after  an  hour's  interval.  The  al- 
kaline treatment  can  be  continued  for  very  long  pe- 
riods without  an}^  ill  effects  whatever.  In  cases  in 
which  the  nervous  element  is  more  disturbed  (sleep- 
lessness, headaches,  over-excitability,  etc.),  we  should 
give  a  good  dose  of  a  bromide  salt.  I  am  in  the  habit 
of  prescribing  strontium  bromide : 

I^  Stront.  brom.  puriss.,     .         .         .         .  12.0     3  iij. 

Aq.  menth.  pip.,     .....  60.0      3  xv. 

S.  One  teaspoonful  twice  daily  in  milk  at  mealtime. 

Sodium  bromide  and  ammonium  bromide  can  be  em- 
ployed in  the  same  way.  The  bromides  should,  how- 
ever, be  given  only  for  a  week  or  two,  and  their  use 
then  discontinued  for  a  short  time,  after  which  they 
may  be  resumed  for  the  same  length  of  time.     Boas 


;304  DISEASES   OF   THE   STOMACH. 

advises  the  admiuistration  of  small  doses  of  morphine 
or  codeine.     He  frequently  j^rescribes  the  following: 

1^  Magnes.  ust, 15.0     3  iijf- 

Morphiiife  hydrochlor.,   ....  0.1     gr.  if. 

M.  f.  pulv.    D.  ad  scat.     S.  A  point  of  a  knife  to  a  teaspoonful 
three  times  daily. 

I  have  very  seldom  seen  the  necessity  of  prescribing 
either  morphine  or  codeine  in  this  affection. 

Of  the  watering-places,  Yichy  and  Neuenahr  are  to 
be  highly  recommended.  For  the  treatment  of  these 
patients  at  home  these  mineral  waters  are  taken  most 
advantageously  in  small  quantities. 

Electricity. — In  cases  of  a  protracted  nature,  the 
direct  application  of  the  electric  current  to  the  inside 
of  the  stomach  is  frequently  of  the  greatest  benefit. 
In  most  instances  the  faradic  current  should  be  ap- 
plied, but  in  cases  in  which  the  pains  are  very  severe 
galvanization  should  be  employed.  As  to  the  mode 
of  application  of  the  current  and  the  length  of  time 
required  for  this  treatment,  see  the  section  on  electric- 
ity. The  electric  current  applied  in  this  manner  ex- 
erts a  stimulating  tonic  influence,  not  only  upon  the 
stomach,  but  also  upon  the  small  and  large  intestines, 
I  have  frequently  seen  cases  of  hyperchlorhydria,  ac- 
companied by  the  most  obstinate  constipation,  per- 
fectly cured  by  means  of  the  current,  even  when  no 
drugs  whatever  had  been  given. 

Gastrosuccorrhcea  Continua  Periodica  (Reichmann). 

Synonyms. — Gastroxynsis  (Eossbach) ;  periodic  con- 
tinuous flow  of  gastric  juice. 

Definition. — Gastrosuccorrhcea    continua    periodica 


GASTROSUCCOEKHCEA    CONTINUA    PERIODICA.  305 

is  a  condition  characterized  by  the  acute  appearance 
of  a  constant  secretion  of  gastric  juice  giving  rise  to 
attacks  of  vomiting  and  severe  pains. 

General  Remarks. — Organic  affections  of  the  pe- 
ripheral or  central  nervous  system  are  present  in  some 
cases  of  this  disorder,  although  it  may  occur  in  per- 
sons who  are  apparently  free  from  nervous  troubles. 
Keichmann  '  was  the  first  to  call  attention  to  the  pe- 
riodic continuous  flow  of  gastric  juice;  a  few  years 
previously  Eossbach  ^  had  described  under  the  name 
of  gastroxynsis  a  nervous  affection  of  the  stomach, 
which  consists  in  a  sudden  appearance  of  severe  head- 
aches accompanied  by  gastric  pains  and  vomiting  of 
very  acid  chyme  or  gastric  juice.  In  accordance 
with  Boas,  I  consider  gastroxynsis  and  gastrosuccor- 
rhoea  continua  periodica  to  be  one  and  the  same  affec- 
tion, and  do  not  think  they  should  be  treated  under 
different  headings. 

Symptomatology. — In  the  midst  of  perfect  health 
a  sensation  of  discomfort  is  experienced  in  the  gastric 
region,  which  is  associated  with  restlessness.  Soon 
afterward  the  discomfort  changes  into  a  rather  pain- 
ful sensation,  and  nausea  appears.  The  patient  is 
compelled  to  occupy  a  recumbent  position.  The 
symptoms  just  described  continue  or  rather  increase 
in  severity,  and  in  about  an  hour  or  two  the  nausea 
ends  in  vomiting  of  a  large  quantity  of  gastric  con- 
tents. The  patient  may  now  feel  a  little  relieved  for 
a  short  time,  but  soon  the  same  symptoms  return. 
The  appetite  is  entirely  lost  and  instead  there  is  ex- 

'  Eeichmann  :  Berl.  klin.  Wochenschr.,  1882,  No.  40. 
2 Eossbach:  Deutsch.  Arch.  f.  klin.  Med.,  1885,  Bd.  35. 
20 


30G  DISEASES   OF   THE   STOMACH. 

treme  thirst.  The  more  the  patient  drinks  the  more, 
as  a  rule,  he  has  to  vomit.  If  he  abstains  from  drink- 
ing, the  vomiting  is  less  frequent,  but  persists  never- 
theless. Thus,  as  a  rule,  in  the  middle  of  the  night 
or  early  in  the  morning,  the  patient  has  to  vomit  a 
large  quantity  of  a  watery  liquid  which  is  very  acid 
in  character,  and  either  quite  clear  or  greenish  from 
the  admixture  of  bile.  If  this  liquid  be  examined  it 
will  be  found  that  free  hydrochloric  acid  is  present 
in  large  quantities,  as  are  the  ferments  (rennet  and 
pepsin).  No  food  particles  can  be  discovered  in  the 
fluid.  It  consists  of  either  clear  gastric  juice  or  gas- 
tric juice  with  admixture  of  a  little  bile.  After  such 
an  attack  frequently  a  constant  desire  to  vomit  per- 
sists, and  the  patient  suffers  from  very  violent  and 
painful  retching.  Often  a  quarter  of  an  hour  after 
the  last  paroxysm,  the  patient's  efforts  to  vomit  cause 
a  small  quantity  of  clear  yellow  bile  to  be  ejected. 
Even  if  the  patient  absolutely  abstains  from  all  kinds 
of  food  and  drink,  a  few  hours  later  a  largo  quantity 
of  gastric  juice  may  again  be  vomited.  The  patient 
in  this  condition  is  hardly  able  to  sleep  for  any  length 
of  time,  as  the  pain  awakens  him  soon  after  he  has 
fallen  asleep. 

The  abdomen,  as  a  rule,  is  sunken.  The  patient 
looks  extremely  pale,  and  his  extremities  are  fre- 
quently cold.  Severe  headaches  often  accompany  this 
train  of  symptoms,  and  constipation  is  almost  a  con- 
stant concomitant.  After  this  condition  has  lasted 
for  two  or  three  days,  or  sometimes  even  longer,  the 
nauseous  feeling  begins  to  disappear,  the  pains  sub- 
side, and  the  patient  experiences  for  the  first  time  a 


GASTEOSUCCORRHCEA   COXTIXUA   PERIODICA.         307 

desire  for  food.  He  is  now  able  to  eat  without  vom- 
iting, and  in  a  day  or  two  feels  like  hiroself  again.  It 
is  characteristic  of  this  affection  that  the  symjDtoms 
disappear  almost  suddenly,  and  that  the  patient  who 
seemed  to  he  in  a  wretched  state  a  few  hours  before 
may  now  appear  nearly  well. 

After  a  period  of  perfect  euphoria,  varying  from 
several  weeks  to  a  few  months  or  a  year  or  even  long- 
er, a  similar  attack  may  occur.  The  attacks  may 
then  either  recur  after  the  same  period  of  time,  or  the 
intermissions  of  health  may  become  gradually  shorter, 
so  that  ultimately  the  patient  has  hardly  recuperated 
from  his  last  attack  before  a  new  one  supervenes. 
The  latter  condition  forms  the  intermediary  stage 
between  periodic  and  chronic  gastrosuccorrhoea. 

During  the  free  intervals  the  gastric  secretion  takes 
place  either  in  a  perfectly  normal  manner  or  hyper- 
chlorhydria  may  exist.  In  either  case,  however,  the 
stomach  remains  free  from  secretion  in  its  empty 
state. 

The  following  cases  may  serve  as  good  illustrations 
of  this  affection : 

Case    I. — R.   B.    I ,    aged   37,    business    man. 

During  1890  and  1891  patient  had  several  attacks  of 
the  then  prevailing  grippe.  In  December,  1892,  after 
the  third  attack  of  the  grijDpe.  he  was  taken  ill  with  a 
stomach  trouble,  the  nature  of  which  patient  describes 
as  follows :  "'  I  was  seized  suddenly  with  a  fit  of  vomit- 
ing, entirely  emptying  the  stomach  apparently,  but 
followed  by  successive  spells,  at  an  interval  of  one  to 
two  hours,  accompanied  by  the  most  intense  pain. 
This  would  last  from  twenty -four  to  thirty-six  hours, 
and  sometimes  forty-eight,  after  which  the  stomach 


308  DISEASES   OF   THE   STOMACH. 

would  gradual!}'  quiet  down  so  that  nourishment  in 
the  form  of  milk — either  hot  milk  or  kumjss — could 
be  taken  in  small  quantities  at  intervals  of  about  two 
hours,  until  a  normal  condition  was  restored,  which 
usually  took  from  two  to  three  days  to  accomplish. 

"The  character  of  the  vomit  was,  first,  that  of  un- 
digested food,  followed  by  a  strong  and  very  acid  fluid 
of  a  whitish,  and  finally  of  a  greenish  color,  consisting 
principally  of  bile.  After  each  of  the  spells  men- 
tioned the  intense  pain  would  subside,  and  I  would 
fall  asleep — to  be  awakened  again  by  a  recurrence  of 
the  pain — the  intervals  of  sleep  and  suffering  varying 
from  an  hour  to  three  as  I  became  better,  and  contin- 
uing until  vomiting  had  ceased. 

"During  all  these  spells  I  was  exceedingly  nervous 
— the  slightest  noise  or  vibration  causing  pain  and 
sometimes  causing  the  vomiting.  General  condition 
after  becoming  able  to  sit  up  was  one  of  extreme 
weakness — having  lost  from  ten  to  twenty  pounds,  as 
the  attacks  were  longer  or  shorter. 

"During  1893  I  was  ill  four  or  five  times,  in  1894 
as  often,  and  in  1895  four  times.  Weight  previous 
to  griiDpe  averaged  135  to  138  pounds;  since  these  at- 
tacks it  has  varied  from  125  to  133." 

Present  Condition. — July  22d,  1895. — Chest  organs 
normal.  The  palpation  of  the  abdomen  does  not  re- 
veal any  pathological  condition.  The  splashing  sound 
can  be  easily  produced  in  the  gastric  region,  and  ex- 
tends downward  to  about  two  fingers'  width  below 
the  navel.  Knee  reflex  present.  Urine  does  not  con- 
tain any  sugar  or  albumin.  Besides  the  above-de- 
scribed attacks  of  vomiting,  patient  complains  of  a 
feeling  of  heaviness  in  his  gastric  region  about  one 
hour  after  meals,  and  of  slight  constipation. 

July  23d. — Examination  of  the  gastric  contents  one 


GASTKOSUCCORRHCEA   CONTINUA   PERIODICA.         309 

hour  after  Ewald's  test  breakfast:  HCl  +,  acidity  = 
100,  free  HCl  =  86. 

October  8th. — Patient  is  in  bed  suffering  from  one 
of  the  attacks  mentioned ;  he  has  vomited  several 
times  during  the  day  and  is  suffering  from  intense 
pain.  On  inspection  the  abdomen  is  shghtly  sunken; 
on  palpation  the  whole  gastric  region  is  found  ex- 
tremely sensitive  and  painful  to  pressure.  The  hands 
and  also  the  face  (particularly  nose  and  forehead)  are 
somewhat  cold ;  pulse,  110;  temperature,  98°  F.  The 
vomited  matter  consists  of  a  pretty  clear  fluid  with 
an  abundant  admixture  of  mucus;  no  food  particles 
can  be  discovered  in  the  liquid.  On  chemical  exami- 
nation free  HCl  as  well  as  pepsin  and  rennet  are  found 
present  in  large  amount.  Patient  complains  of  in- 
tense thirst.  Under  the  administration  of  opiates  he 
grew  better  and  was  able  to  leave  his  bed  after  three 
days. 

Case  II. — George  N.  J ,  42  years  of  age,  mer- 
chant, suffered  for  five  years  from  frequently  appear- 
ing attacks  of  pains  in  the  region  of  the  stomach. 
These  attacks  were  usually  accompanied  by  vomiting 
of  highly  acid  substances ;  they  recurred  once  every 
three  to  four  weeks  and  lasted  about  three  days. 
During  the  attack  the  patient  felt  miserable  and 
down-hearted,  suffered  from  severe  pains;  was  not 
able  to  eat  anything  and  vomited  frequently.  When 
the  attack  was  over  he  felt  perfectly  we]l,  except  that 
his  sleep  was  somewhat  disturbed. 

The  physical  examination  shows:  Chest  and  ab- 
dominal organs  intact;  the  patellar  reflex  present; 
stomach  not  dilated  (the  site  of  the  stomach  having 
been  determined  by  gastro-diaphany). 

August  31st,  1891. — One  hour  after  test  breakfast, 
HCl  +  ,  acidity  =  Q6. 


310  DISEASES   OF   THE   STOMACH. 

The  patient  was  directly  gastro-faradized  for  a  pe- 
riod of  two  months.  He  had  no  attack  during  the 
time  of  treatment,  nor  any  thus  far  after  it  was  dis- 
continued ;>  sleeps  w^ell  and  feels  stronger  and  full  of 
life. 

Diagnosis.  — The  diagnosis  of  gastrosuccorrhoea  con- 
tinua  periodica  can  be  made  by  the  above-described 
symptoms,  in  connection  with  the  examination  of  the 
vomited  matter  (which  is  found  to  consist  principally 
of  clear  gastric  juice  without  admixture  of  much 
food),  or  with  the  examination  of  the  stomach  in  the 
fasting  condition  by  means  of  the  tube  (which  results 
in  the  withdrawal  of  a  considerable  quantity  of  clear 
gastric  juice).  Inasmuch  as  similar  attacks  of  gas- 
trosuccorrhoea may  occur  as  a  consequence  of  either 
an  open  ulcer  or  a  cicatrix  within  the  stomach,  the 
pylorus,  or  the  duodenum,  it  will  be  necessary  to 
exclude  such  organic  affections  before  making  a  diag- 
nosis of  continuous  periodic  gastric  flow,  which  we 
consider  to  be  a  nervous  affection.  It  will  also  be  of 
importance  to  exclude  organic  spinal  or  cerebral  trou- 
bles, which  may  cause  a  similar  disorder  of  reflex 
origin. 

Prognosis.— ll]i%  prognosis  of  pure  gastrosuccor- 
rhoea continua  periodica  is,  as  a  rule,  not  bad.  In 
many  instances  it  is  possible  either  to  make  the  at- 
tacks less  severe,  or  in  some  instances  to  effect  a  cure 
by  rational  treatment. 

Treatment. — It  will  always  be  advisable  to  analyze 
the  gastric  juice  of  the  patient  during  the  free  inter- 
vals. If  hyperchlorhydria  is  found  this  will  have  to 
be  treated   (see  p.  206),   even  if  there   should   be  no 


GASTROSUCCORRHCEA   CONTINUA   PERIODICA.         311 

subjective  complaints;  for  hyperchlorbydria  is  fre- 
quently, although  not  always,  the  cause  of  such  at- 
tacks. At  any  rate,  a  hygienic  way  of  living  should 
he  inaugurated  by  the  physician.  I  am  in  the  habit 
of  prescribing  a  good-sized  dose  of  bromide  as  soon  as 
the -patient  feels  an  attack  coming  on,  and  find  that 
occasionally  it  may  be  cut  short  at  the  very  beginning. 
In  some  instances  the  attack,  although  not  inter- 
rupted in  its  progress,  is  thereby  rendered  less  severe. 
When  the  attack  has  appeared  the  patient  must  be 
kept  in  bed.  A  hot- water  bag  is  placed  over  the  gas- 
tric region,  and  if  the  pains  are  severe  an  opiate, 
either  alone  or  in  combination  with  belladonna,  is  ad- 
ministered. During  the  first  day  of  the  attack  no 
nourishment  whatever  should  be  given.  A  teaspoon- 
ful  of  cold  water  or  a  small  ice  pill  can  be  adminis- 
tered from  time  to  time,  especially  if  the  patient  is 
very  thirsty.  The  next  day  small  quantities  of  milk, 
matzoon,  or  egg  water,  one  or  two  tablespoonfuls,  are 
given  every  hour.  On  the  third  day  the  quantity  of 
nourishment  may  be  increased  to  half  a  cupful  at  a 
time  administered  every  two  hours,  and  besides  the 
above  liquid  food  the  white  of  a  hard-boiled  egg 
chopped  up  fine  may  also  be  given  (one  or  two  eggs  a 
day).  On  the  fourth  day  meat  (scraped,  raw,  or 
broiled)  may  be  tried,  and  afterward  the  diet  gradu- 
ally arranged  as  for  cases  of  hyperchlorbydria.  The 
system  of  diet  as  laid  down  here  for  every  day  from 
the  beginning  of  the  attack  will  certainly  depend 
upon  the  condition  of  the  patient,  and  will  have  to  be 
modified  accordingly.  As  there  is  always  constipa- 
tion during  the  attack,  it  will  be  best  to  move  the 


312  DISEASES   OF   THE   STOMACH. 

"bowels  on  the  second  or  third  day,  either  hy  a  glycerin 
supjDOsitory  or  by  a  large  injection  of  water  (a  quart 
of  water  and  a  teaspoonful  of  salt),  or  an  injection  of 
sweet  oil  (one  pint). 

Gastrosiiccorrhcea  Continua  Chronica  {Reichmann). 

Synonyms. — Chronic  continuous  flow  of  gastric 
juice:  Reichmann's  disease. 

Definition. — Reichmann,'  in  1882,  described  under 
the  above  name  a  disorder  which  is  characterized  by  a 
constant  secretion  of  gastric  juice,  even  in  the  ab- 
sence of  food  in  the  stomach.  Considerable  quanti- 
ties of  gastric  juice  can  be  withdrawn  from  the  stom- 
ach in  the  morning,  even  in  the  fasting  condition. 

General  Remarks. — In  describing  this  new  disease 
Reichmann  in  1887  mentioned  that  he  had  observed 
sixteen  cases.  An  exact  scientific  diagnosis  had  been 
made,  however,  only  in  six  of  them.  "In  the  re- 
maining cases,"  says  Reichmann,  "I  was  able  to  find 
in  the  stomach  in  the  morning  in  the  fasting  condi- 
tion a  large  quantity  of  a  liquid  containing  hydro- 
chloric acid  and  pepsin,  and  exhibiting  digestive 
properties,  but  also  containing  much  peptone  and  rem- 
nants of  amylaceous  food." 

Among  the  six  cases  which  Reichmann  considered 
as  typical  of  gastrosuccorrhoea  chronica,  I  think  that 
only  one  (Case  3)  deserves  this  name,  for  the  remain- 
ing five,  aside  from  the  constant  secretion  of  gastric 
juice,  presented  other  important  lesions  of  the  stom- 
ach,  which  in  all  probability  were  rather  the  cause 

'Reichmann-.  Berl.  klin.  Wochenschr. ,  1882.   No.  40;  1884,  No. 
48,  and  1887,  No.  13. 


GASTROSUCCOREHCEA   COXTIXUA   CHRONICA.         olo 

than  the  effect  of  the  coostant  gastric  flow.  In  all 
the  cases  described  by  Eeichmann,  except  in  Case  3, 
the  stomach  in  the  fasting  condition  contained  a  con- 
siderable quantity  of  liquid,  consisting  of  gastric 
juice,  and  containing  only  amylaceous  food  remnants. 
When  the  stomach  had  been  washed  out  on  the  pre- 
vious night,  and  the  patient  had  abstained  from  food 
or  drink,  the  stomach  in  the  morning  nevertheless 
contained  clear  gastric  juice.  These  cases  are  then 
undoubtedly  cases  of  dilatation  of  the  stomach,  or, 
more  correctly  speaking,  of  stenosis  of  the  pylorus, 
in  which  hypersecretion  must  be  considered  as  a  con- 
comitant factor.  Eeichmann,  and  following  him,  es- 
pecially the  French  writers  Bouveret,^  Debove  and 
Remond,'  and  among  the  Germans  Eiegel,"  have  laid 
too  little  stress  upon  the  distinction  between  the  con- 
stant flow  of  gastric  juice  and  dilatation  of  the  stom- 
ach due  to  stenosis  of  the  pylorus.  On  this  account 
the  picture  given  by  these  authors  of  the  true  gastro- 
succorrhoea  chronica  bears  a  closer  resemblance  in 
many  points  to  that  of  dilatation  of  the  stomach  than 
to  the  picture  of  the  affection  in  question.  Inasmuch 
as  the  treatment  of  cases  of  stenosis  of  the  pylorus  is 
in  most  essential  points  different  from  cases  of  gastro- 
succorrhoea  (I  need  only  mention  that  the  most  ra- 
tional treatment  for  the  former  is  a  surgical  one),  it 
is  absolutely  necessary  strictly  to  differentiate  between 
these  two  conditions. 

About   two  years   ago  Schreiber,^   of   Konigsberg, 

'  Bouveret :  "Traite  des  Maladies  de  rEstomac. " 

2  Debove  et  Eemond  :  "Les  Maladies  de  rEstomac." 

2  Eiegel :  Deutsche  med.  Worhenschrif t,  1893.  Nos.  31  imd  32. 

^Schreiber:  Deutsche  med.  Wochenschr.,  1893,  Nos.  29  und  30. 


314  DISEASES   OF   THE   STOMACH. 

published  an  extensive  paper  in  which  he  expressed 
doubt  as  to  the  existence  of  the  new  disease,  regard- 
ing all  the  cases  described  by  Eeichmann  as  cases  of 
dilatation  of  the  stomach  with  stagnation  of  food. 
Shortly  afterward  two  other  important  papers  ap- 
peared with  reference  to  this  question.  Riegel 
defended  Reichmann's  views,  while  Martins'  was  in- 
clined to  favor  Schreiber's  opinion.  Whether  Schrei- 
ber's  view,  that  the  stomach  normally  secretes  gastric 
juice  even  while  in  its  empty  state,  is  correct  or  not, 
is  a  question  that  is  quite  difficult  to  decide,  although 
I  am  personally  of  the  opinion  that  when  there  is  no 
food  in  the  stomach  there  is  no  secretion.  But  leav- 
ing aside  this  question  about  the  physiology  of  the 
stomach,  there  is  no  doubt  that,  as  a  rule,  the  stomach 
in  the  fasting  condition  does  not  contain  any  con- 
siderable quantity  of  gastric  juice.  Whenever  larger 
quantities  are  found  the  stomach  must  be  regarded 
as  affected. 

Etiology. — Gastrosuccorrhoea  chronica  is  met  with 
much  more  frequently  in  men  than  in  women.  In 
some  instances  there  is  present  besides  this  affec- 
tion some  other  functional  neurotic  disturbance.  In 
three  of  my  cases  the  latter  was  very  marked.  Thus 
one  of  these  patients  complained  of  a  burning  sensa- 
tion all  over  his  limbs,  which  lasted  for  three  months 
and  then  suddenly  disappeared.  Like  hyperchlor- 
hydria,  gastrosuccorrhoea  seems  to  arise  from  great 
mental  worry  or  strain. 

Symptomatology. — After  a  more  or  less  prolonged 
period  of  different  dyspeptic  disturbances  which   are 

'  Marti  us  :  Deutsche  nied.  Wochenschrift,  1894. 


•    GASTROSUCCORRHCEA   CONTINUA   CHRONICA.         315 

similar  in  character  to  those  caused  by  hyperchlorhy- 
dria,  there  ajDpears  a  pronounced  sensation  of  pain  sev- 
eral hours  after  and  shortly  before  meals.  Very  soon 
vomiting  supervenes  as  a  new  symptom.  At  first  it 
occurs  only  occasionally,  but  constantly  grows  more 
frequent  until  at  last  there  may  be  one  or  several 
vomiting  spells  every  day.  The  vomiting  appears 
most  frequently  soon  after  breakfast,  sometimes  also 
after  supper.  In  only  a  few  cases  does  it  occur  in  the 
night,  about  two  or  three  o'clock,  preceded  by  a  long 
and  severe  attack  of  pain.  The  vomited  matter  is  al- 
ways very  acid  and  more  or  less  liquid.  The  night 
vomit  consists,  as  a  rule,  of  a  clear  liquid  containing 
hardly  any  food. 

The  appetite  is  generally  increased,  although  there 
are  exceptions  to  this  rule.  In  some  cases  periods  of 
extreme  hunger  alternate  with  periods  of  pronounced 
anorexia.  In  most  cases  the  sensation  of  thirst  is 
greatly  increased.  In  all  of  my  cases  constipation  was 
marked.  In  some  there  was  loss  of  weight,  but  none 
of  my  patients  was  emaciated  in  any  great  degree. 

Diagnosis. — Although  the  symptoms  described 
might  suggest  the  presence  of  gastrosuccorrhoea  in  cer- 
tain cases,  the  exact  diagnosis  can  be  made  only  by  a 
repeated  examination  of  the  stomach  in  the  fasting 
condition.  By  inserting  the  tube  into  the  stomach, 
and  telling  the  patient  to  exert  some  pressure  with  his 
abdominal  muscles,  more  or  less  liquid  (60  to  100  c.c.) 
is  obtained  from  the  stomach.  This  contains  no  food 
particles,  but  exhibits  all  the  properties  of  the  gastric 
juice.  It  may  look  greenish  from  the  admixture  of 
bile,  but  this  is  not  an  important  sign.     The  filtrate, 


olG  DISEASES   OF   THE   STOMACH. 

as  a  rule,  shows  a  somewhat  increased  degree  of 
acidity.  It  never  contains  any  starchy  products  (ab- 
sence of  erythrodextrin,  achroodextrin,  and  sugar). 

Microscopically  no  sarcinse  or  other  signs  of  decom- 
position are  found.  Frequently  cell  nuclei  are  met 
with  in  large  numbers.  In  examining  the  patient  one 
hour  after  Ewald's  test  breakfast,  the  gastric  contents 
will  be  found  to  contain  more  liquid  than  usually,  and 
the  degree  of  acidity  will  be  quite  high  (80  to  l!^(i). 
As  a  rule,  the  degree  of  acidity  of  the  gastric  contents 
is  higher  than  that  of  the  gastric  juice  when  with- 
drawn from  the  stomach  in  the  fasting  condition.  In 
examining  the  filtrate  of  the  gastric  contents  with 
reference  to  the  starchy  products,  it  will  be  found  that 
the  Lugol  solution  will  produce  a  deep  violet  or  even 
blue  color,  showing  that  the  starch  has  not  been  much 
changed.  A  thin  disc  of  hard-boiled  egg  will  be 
digested  in  the  filtrate  at  blood  temperature  in  about 
half  an  hour  to  an  hour.  The  difference  as  to  the  de- 
grees of  digestion  of  the  albuminates  and  starches  (the 
former  being  more  quickly,  the  latter  much  more 
slowly  digested)  can  be  best  studied  after  Leube- 
Riegel's  test  dinner.  Three  to  four  hours  after  such 
a  dinner  the  obtained  gastric  contents  show  hardly 
any  meat  particles  whatever  (all  being  digested), 
whereas  particles  of  starchy  food  form  the  principal 
part  of  the  mixture.  In  this  way  the  difference  be- 
tween the  digestion  of  meats  and  starchy  foods  exist- 
ing in  this  affection  is  seen  at  once. 

Differential  Diagnosis. — In  making  the  diagnosis 
of  gastrosuccorrhcea,  all  organic  lesions  of  the  stomach 
(ulcer  and  stenosis  of  the  pylorus)  which  are  liable  to 


GASTKOSUCCORRHCEA   CONTIXUA   CHRONICA.         317 

be  accompanied  with  gastrosuccorrhoea  will  have  to 
be  excluded.  According  to  my  experience,  it  is  easy 
to  exclude  stenosis  of  the  pylorus,  but  not  an  ulcer. 
In  stenosis  of  the  pylorus  the  stomach  in  the  fasting 
condition  is  also  found  to  contain  a  liquid,  but  this  is 
mix^d  with  food  and  the  filtrate  always  shows  the 
presence  of  starch  or  sugar  products.  But  the  main 
thing  is  that  food  articles  can  be  seen  even  with  the 
naked  eye,  whereas  the  liquid  found  in  the  stomach  in 
case  of  genuine  gastrosuccorrhoea  does  not  contain  any 
food  particles,  as  described  above.  The  presence  of  an 
ulcer  will  be  suspected  if  there  has  been  a  preceding 
hsematemesis  or  melsena  or  a  circumscribed  spot  in  the 
gastric  region  very  painful  to  the  slightest  jDressure. 
The  absence  of  these  symptoms  will  tend  to  justify  the 
diagnosis  of  gastrosuccorrhoea. 

In  this  respect  I  agree  with  Eeichmann  as  to  the 
existence  of  a  pathological  continuous  gastric  succor- 
rhoea,  although  I  restrict  this  name  to  cases  not  pre- 
senting any  organic  lesions  of  the  stomach.  When- 
ever the  latter  exist,  I  deem  it  best  to  look  upon  the 
accompanying  gastric  succorrhoea  as  a  consequence  of 
the  main  trouble,  but  not  as  the  cause  of  the  organic 
lesion.  According  to  my  experience,  which  coincides 
with  that  of  Ewald,  cases  of  genuine  gastrosuccor- 
rhoea chronica  are  quite  rare.  They  are  less  frequent 
than  those  of  periodic  gastrosuccorrhoea.  During  the 
last  eight  years  I  have  met  with  eight  cases  of  this 
affection,  one  of  which  I  *  published  in  1887.  The  fol- 
lowing is  the  description  of  one  of  my  recently  ob- 
served typical  cases  of  gastrosuccorrhoea : 

*  Max  Einhorn  :  New  Yorker  medicinische  Presse,  1887. 


318  DISEASES   OF   THE   STOMACH. 

A.  S ,  21  years  old,  has  suffered  since  early  youth 

from  digestive  troubles.  As  far  back  as  he  can  re- 
member, he  has  felt  hungry  very  soon  after  meals 
(one  hour).  The  bowels,  although  usually  regular, 
were  at  times  very  constipated.  Patient  was  always 
weakly,  hut  in  the  last  three  years  he  has  been 
troubled  to  a  much  greater  degree.  He  felt  extremely 
weak,  became  dizzy  after  meals,  and  was  overcome  by 
a  feeling  of  sleepiness.  The  bowels  became  consti- 
pated all  the  time.  During  the  last  six  or  seven 
months  there  was  a  sensation  of  extreme  weakness  in 
the  hands  and  feet.  The  appetite  was  constantly  in- 
creased, and  a  hungry  feeling  .  appeared  very  fre- 
quently. For  the  past  three  months  there  had  been  a 
burning  sensation  in  the  gastric  region,  which  in- 
creased in  severity  about  an  hour  or  two  after  meals. 
From  that  time  on  the  patient  began  to  vomit  fre- 
quently. The  vomiting,  as  a  rule,  occurred  very  soon 
after  a  meal,  although  occasionally  it  took  place  either 
in  the  middle  of  the  night  or  in  the  morning  before 
breakfast.  Patient  had  lost  lately  in  weight  (about 
ten  pounds). 

Present  Condition. — Chest  organs  intact.  On  pal- 
pation, the  gastric  region  is  somewhat  sensitive  to  pres- 
sure. There  is,  however,  no  circumscribed  painful 
area.  A  splashing  sound  can  be  produced  extending 
to  about  one  finger's  width  above  the  navel.  The 
tongue  is  thickly  coated.  The  color  of  the  lips  and 
cheeks  is  quite  good,  and  the  patient  does  not  look 
emaciated.  The  knee  reflex  is  present,  and  the  urine 
does  not  contain  anything  abnormal.  The  examina- 
tion of  the  stomach  one  hour  after  a  test  breakfast 
showed  the  quantity  of  chyme  to  be  small  (about  30 
c.c);  hydrochloric  acid  -\-,  acidity  =  100. 

The  examination  of  the  stomach  in  the  fasting  con- 
dition revealed  the  presence  of  a  considerable  quantity 


GASTROSUCCOREHCEA   COXTIXUA   CHRONICA.  319 

of  pure  gastric  juice;  120  c.c.  of  a  somewhat  turbid 
liquid,  not  containing  any  food  reranants  whatever, 
were  withdrawn  with  the  tube.  This  fluid  contained 
free  hydi'ochloric  acid,  had  an  acidity  of  SO,  gave  only 
weak  biuret  reaction,  while  erythrodextrin,  dextrin, 
and  sugar  were  wholly  absent.  During  the  first  three 
months  of  treatment  the  condition  of  the  stomach  in 
reference  to  its  secretion  of  juice  did  not  change  in 
any  way.  Repeated  examinations,  which  had  been 
made  in  the  fasting  condition  of  the  patient,  always 
gave  the  same  result:  presence  of  about  100  c.c.  or 
more  of  pure  gastric  juice. 

The  treatment  consisted  at  first  in  regulation  of  the 
diet,  and  in  the  administration  of  large  doses  of  alka- 
lies. Later  on  washing  of  the  stomach  and  spraying 
of  the  organ  with  a  1  to  2:1,000  solution  of  nitrate  of 
silver  was  instituted.  The  latter  means  proved  more 
effective  than  the  former  treatment,  and  after  about 
two  weeks  it  was  noticed  that  the  stomach  in  the  fast- 
ing condition  contained  considerably  smaller  quantities 
of  juice.  Frequently  but  30  or  2f_'  c.c.  of  juice  were 
found.  The  spraying  was  continued  for  two  months, 
after  which  time  the  stomach  in  the  fasting  condition 
was  usually  found  empty.  This  objective  improve- 
ment was  connected  with  a  subjective  amelioration  of 
all  the  symptoms:  the  vomiting  ceased,  the  hunger 
was  much  less  marked,  the  dizziness  subsided,  and  the 
patient  felt  stronger  and  could  do  his  work  much 
better.  The  examination  of  the  stomach  one  hour 
after  the  test  breakfast,  however,  showed  that  the 
hyperchlorhydria  still  persisted.  In  this  case  we  fre- 
quently tried  to  determine  the  motor  (transportation) 
faculty  of  the  stomach.  One  and  a  half  hours  after 
Ewald's  test  breakfast,  as  a  rule,  the  stomach  was 
found  empty,  showing  that  this  faculty  was  rather 
increased.     This  is  of  interest,  inasmuch  as  it  shows 


320  DISEASES   OF   THE   STOMACH. 

that  continuous  hypersecretion  need  not  be  associated 
with  sluggishness  in  the  muscular  action  of  the 
organ,  a  theory  which  is  accepted  by  most  investiga- 
tors who  have  written  on  the  subject. 

The  following  is  another  typical  case  of  continuous 
hypersecretion. 

S ,  40  years  old,  has  been  suffering  from  diges- 
tive disturbances  since  1893.  The  principal  symptoms 
consist  in  pains  appearing  in  the  gastric  region  about 
three  hours  after  meals  and  also  early  in  the  morn- 
ing before  arising.  The  appetite  was  always  good. 
Thirst  is  frequently  greatly  marked  and  with  it  a  sen- 
sation of  dryness  in  the  mouth. 

The  pains  are  almost  always  relieved  either  by  food 
or  by  bicarbonate  of  soda.  Steady  brain  work,  strain 
in  business,  and  worry  greatly  aggravate  the  condi- 
tion, while  a  stay  in  the  country  and  rest  materially 
diminish  the  symptoms.  There  were  several  inter- 
missions of  the  symptoms  extending  over  a  period  of 
a  few  months'  duration.  But  thus  far  they  have 
always  returned.  Constipation  exists  in  a  high  de- 
gree. 

On  examination  the  stomach  is  found  to  extend  to 
two  fingers'  width  below  the  navel;  the  gastric  region 
is  not  painful  to  pressure. 

One  hour  after  test  breakfast:  Quantity  of  chyme 
(consisting  of  fine  pieces  of  roll  and  a  watery  liquid) 
amounts  to  500  c.c.  HCl  +,  acidity  =  108,  free  HCl 
=  02,  erythrodextrin  +  much. 

In  the  fasting  condition,  the  stomach  contains  130 
c.c.  of  a  watery  liquid  not  mixed  with  any  particles 
of  food.  HCl  +,  acidity  =  100,  free  HCl  =  90,  ery- 
throdextrin =  0. 

Several  other  examinations  gave  similar  results, 
and  for  quite  a  while  the  stomach  in  the  fasting  con- 


GASTROSUCCOKKHCEA    CONTINUA    CHRONICA.         321 

dition  usually  contained  from  70  to  140  c.c.  of  clear 
gastric  juice.  The  treatment  consisted  in  the  ap- 
plication of  intragastric  galvanization  and  spray- 
ing with  nitrate  of  silver.  The  symptoms  gradually 
subsided. 

Prognosis. — According  to  my  experience,  the  prog- 
nosis of  gastrosuccorrhoea  is  not  bad.  As  a  rule, 
most  patients  improve  under  rational  treatment. 
Frequently,  how^ever,  there  are  relapses.  Some  very 
obstinate  cases  are  occasionally  met  v^ith,  and  the 
trouble,  although  yielding  somewhat  to  treatment, 
may  persist  for  years.  There  is,  however,  no  danger 
of  a  fatal  issue  resulting  from  this  disease  alone. 

Treatment.' — As  we  have  seen,  gastrosuccorrhoea 
is  always  associated  with  hyperchlorhydria.  The 
treatment  of  the  latter  condition  in  reference  to  diet, 
drugs,  and  mode  of  living  will  have  to  be  resorted  to 
here  also.  With  reference  to  diet,  I  have  only  to  add 
that  it  is  of  great  importance  not  to  permit  the  patient 
to  partake  of  any  large  quantities  of  liquid.  In  this 
affection  more  stress  must  be  laid  upon  this  point  than 
in  hyperchlorhydria. 

Medicaments. — The  treatment  of  gastrosuccorrhoea 
must  be  directed  toward  decreasing  the  undue 
amount  of  gastric  secretion.  With  this  end  in  view, 
Voinovitch  '  recommepds  the  use  of  atrojDine  in  doses 
of  2  mgm.  (gr.  ^)  daily.  Bouveret  prefers  morphine 
to  atropine.  Following  the  advice  of  Leubuscher 
and  Schaeffer,'  he  administered  as  much  as  2  to  3 
cgm.  (gr.  -|-i)  of  sulphate  of  morphine  three  times 

^  Voinovitch  :  La  Semaine  medicale,  April  6th,  1892. 

2  Leubuscher  imd  Schaeflfer  :  Deutsche  med.  Wocheuschr.,  1892. 

21 


32-2 


DISEASES   OF   THE   STOMACH. 


daily  by  subcutaneous  injection.  This  author  doubts, 
however,  whether  this  treatment,  which  seems  to  be 
effective  in  the  initial  state  of  the  affection,  will  prove 
useful  in  cases  that  have  progressed  further.  The 
use  of  either  atropine  or  morphine  may  be  tried  for 
a  short  time,  but  they  should  never  be  administered 
for  a  long  period.  The  subcutaneous  injections  of 
morphine  especiall\'  should  be  avoided,  as  the  patient 
runs  the  risk  of  becoming  an  habitue  of  this  drug. 

Large  doses  of  subuitrate  of  bismuth  (:2  gm.  or  half 
a  drachm  in  a  wineglassful  of  water  three  times  daily 
half  an  hour  before  meals)  seem  to  have  occasionally 
very  good  effects.  Wolff  '  recommends  Carlsbad  salt 
or 


IJ  Sod.  sulph., 
Potass,  sulph., 
Sod.  clilorat. , 
Sod.  carbon., 
Sod.  bicarbon., 
M.  f.  pulv.     Half  a 
water  three  times  dailv 


30.0 
5.0 
30.0 
25.0 
10.0 


teaspoonful  in  half  a  glassful  of  lukewarm 
the  first  portion  to  be  taken  in  the  fasting 
condition,  the  second  two  hours  before  the  midday  meal,  and  the 
third  two  hours  before  supper. 


Riegel  *  likewise  speaks  highly  of  this  mode  of  treat- 
ment. 

Lavage. — Reichmann,  and  later  Riegel,  recommend 
the  use  of  lavage  of  the  stomach  as  the  best  means  of 
improving  its  condition.  While  Riegel  washes  out  the 
stomach  in  the  evening  six  to  seven  hours  after  the 
heavy  meal.  Reichmann  and  most  writers  administer 
the  lavage  in  the  fasting  condition.  The  latter  way 
is  also  employed  by  myself:  it  has  the  advantage  that, 

'  Wolff:  Zeitschrift  f.  klin.  Med..  Bd.  xvi. 

-  F.  Riegel:  "Die  Erkrankungen  des  Magens, "  "Wien,  1896,  p. 
268. 


GASTROSUCCORRHCEA   CONTINUA   CHRONICA.         323 

by  emptying  the  stomach  in  the  fasting  condition,  we 
are  better  enabled  to  judge  of  the  quantity  of  juice 
present,  at  a  time  when  normally  there  should  be 
none;  and  also  that  no  food  whatever  is  removed  from 
the  stomach. 

Instead  of  lavage  Boas  recommends  emptying  the 
stomach  by  means  of  a  tube  in  the  fasting  condition 
(expression  method). 

In  order  to  combat  more  effectively  the  undue  secre- 
tion, Eeichmann  recommends  adding  nitrate  of  silver 
to  the  water  used  in  washing  out  the  stomach.  After 
it  has  been  washed  out  with  plain  water,  300  c.c.  of 
a  1  or  2  :  1,000  solution  of  nitrate  of  silver  is  poured 
into  the  organ,  and  left  there  for  about  five  minutes, 
when  it  is  withdrawn  by  siphonage. 

Spraying  the  Stomach. — Instead  of  the  latter  pro- 
ceeding I  have  sprayed  out  the  stomach  after  wash- 
ing with  a  1  or  2  : 1,000  nitrate-of-silver  solution.  In 
two  cases  I  found  this  method  of  treatment  of  great 
benefit. 

Direct  Galvanization. — The  first  of  my  observed 
cases  of  gastrosuccorrhcea  chronica  was  a  very  obsti- 
nate one,  and  the  affection  did  not  yield  much  to 
either  the  medicinal  treatment  or  to  the  use  of  lavage. 
I  empirically  tried  direct  galvanization  of  the  organ, 
and  after  a  treatmeut  of  a  few  weeks  the  stomach  be- 
gan to  be  empty  in  the  morning,  and  has  remained  so 
for  several  years.  Since  then  it  has  been  my  custom  to 
make  use  of  this  method  in  this  affection,  and  I  must 
say  that  the  result  has  been  very  gratifying.  Very 
often  I  employ  both  spraying  with  nitrate  of  silver 
and  direct  galvanization,  applying  them  alternately. 


OHAPTEK  X. 

FUNCTIONAL  DISEASES    WITH  VARIABLE 

LESIONS.— Co«^Mmed. 

Achylia  Oastrica. 

Synonyms. — Atrophy  of  the  stomach;  anadenia 
ventriculi;  phthisis  ventriculi. 

Definition. — This  term  embraces  a  class  of  cases  in 
which  there  is  a  permanent  absence  of  gastric  secre- 
tion. 

General  Remarks. — In  1892  I'  suggested  the  term 
"achylia  gastrica"  for  those  conditions  in  which  the 
stomach  apparently  secretes  no  juice  and  in  which 
clinically  the  diagnosis  of  "atrophy  of  the  gastric 
mucosa"  seems  to  be  justifiable.  In  a  paper  referring 
to  this  subject  I  endeavored  to  show  that  cases  of 
achylia  gastrica  and  cases  of  pernicious  anaemia  ought 
to  be  kept  strictly  apart.  Whereas  the  latter,  as  a 
rule,  end  fatally,  the  former  do  not  necessarily  en- 
danger the  life  of  the  patient.  As  a  proof  of  this  view 
I  described  a  case  of  achylia  gastrica  which  I  had 
under  observation  for  four  years  and  whose  condition 
had  meanwhile  somewhat  improved,  and  another  case 
in  which  the  history  given  by  the  patient  made  it  prob- 
able that  the  stomach  had  persisted  in  this  state  of 
juicelessness  for  forty  years.  In  this  case  there  were 
no  subjective  symptoms  present  and  the  patient  used 

'MaxEinhorn:  Medical  Eecord,  June  11th,  1893. 


ACHYLIA   GASTRICA.  325 

to  partake  of  the  heaviest  food  with  perfect  impunity. 
Id  all  these  cases  the  small  intestine  acts  vicariously 
and  completely  replaces  the  lack  of  digestion  of  the 
stomach. 

In  regard  to  the  literature  of  "  atrophy  of  the  gastric 
mucosa"  I  refer  to  the  excellent  paper  of  S.  Fenwick,' 
who  first  described  this  condition  in  cases  of  pernicious 
anaemia,  and  to  the  work  of  Lewy/  Ewald/  Henry 
and  Osier/  Kinnicutt/  Nothnagel,'  and  George 
Meyer.' 

In  all  cases  described  by  these  writers  (mostly  per- 
nicious anaemia)  the  autopsy  showed  the  disappearance 
of  the  gastric  glands.  Henry  and  Osier  have  given 
various  characteristic  drawings  illustrating  the  micro- 
scopic picture  of  this  condition. 

In  most  cases  of  atrophy  of  the  stomach  mentioned 
in  literature  the  sickness  in  question  is  one  in  which 
all  the  functions  of  the  stomach  are  disturbed  and 
which  gradually  leads  to  death.  There  have  been  de- 
scribed, however,  a  few  cases  of  atrophy  of  the 
stomach  in  which  the  clinical  symptoms,  or,  more  cor- 
rectly, the  chemical  analysis  of  the  stomach  contents 
led  to  the  above  diagnosis,  which  by  no  means  seemed 

'S.  Fenwick  :  "Ati-ophy  of  the  Stomach."  The  Lancet,  July, 
1877. 

2  B.  Lewy  :  Berliner  klin.  Wochenschr. ,  1887,  No.  4. 

3C.  A.  Ewald:  ibid.,  1886,  No.  32. 

*  Henry  and  Osier :  American  Journal  of  the  Medical  Sciences, 
vol.  91,  1886,  p.  498. 

^F.  P.  Kinnicutt:  American  Journal  of  the  Medical  Sciences, 
vol.  94,  1887,  p.  419. 

^  Nothnagel :  Deutsch.  Arch,  f .  klin.  Medicin,  Bd.  xxiv. ,  Heft 
4  und  5. 

''George  Meyer:  "Zur  Kenntniss  der  sogenannten  'Magen- 
atrophie. '"     Zeitschrift  fiii- klinische  Medicin,  Bd.  xvi.,  p.  366. 


326  DISEASES    OP    THE    STOMACH. 

to  present  such  a  severe  irreparable  disease.  In  these 
cases  no  autopsies  could  be  made,  and  atrophy  of  the 
stomach,  although  it  must  here  be  conjectured,  is  not 
as  yet  proven  to  exist.  Cases  belonging  to  this  latter 
grouj)  have  been  described  by  Grundzach,'  Ewald,' 
Wolff, ^  Jaworski,*  Boas,"  Eosenheim,"  Litten,''  and 
myself.*  For  these  cases  the  name  achylia  gastrica 
seems  to  be  best  adapted. 

The  recent  literature  on  cases  of  pure  achylia  gas- 
trica (not  complicated  with  pernicious  anaemia)  is  not 
very  extensive.  Simultaneously  with  my  article  on 
"Achylia  Gastrica"  Ewald  "  published  a  paper  entitled: 
"A  Case  of  Chronic  Disability  of  Gastric  Secretion 
(Anadenia  Ventriculi?)."  Ewald 's  views  are  in  per- 
fect accord  with  mine.  The  patient  reported  in  the 
paper  had  been  observed  by  Ewald  for  two  and  a  half 
years.  Although  this  patient  improved  considerably 
in  every  respect  and  gained  forty-two  pounds  in 
weight,  the  chemical  examination  of  the  gastric  con- 
tents showed  a  total  lack  of  juice. 

In  this  country  Allen  A.  Jones'"  has  described  under 

ij.  Grundzach:  Berl.  klin.  Wochenschr. ,  1887,  No.  30. 

*  C.  A.  Ewald  :  "  Ueber  das  Fehlen  der  f reien  Salzsaure  im  Magen- 
inhalt."     Berl.  klin.  Wochenschr.,  1887,  No.  30. 

3L.  Wolff:  ihid. 

■*Javvorski  :  Wiener  medicinische  Wochenschr. ,  1886,  Nos.  49-52. 

*  I.  Boas  :  Miinchener  nied.  Wochenschr. ,  1887,  Nos.  41  und  42. 
^Rosenheim:  Berl.  klin.  Wochenschr.,  1888,  Nos.  51,  52. 

'  M.  Litten  und  Rosengart :  Zeitschr.  f.  klin.  Medicin,  1888,  p. 
573. 

8  Max  Einhorn  :  "  Ein  Fall  von  continuirlichem  Magensaftfluss  und 
ein  Fall  von  vollstandigera  Fehlen  der  Salzsaure  im  Magen."  New 
Yorker  medicinische  Presse,  September,  1888. 

'Ewald:  Berliner  klin.  Wochenschr.,  1892,  Nos.  20  und  27. 
'"Allen  A.  Jones:  New  York  Medical  Journal,  May  27th,  1893,  p. 
573. 


ACHYLIA    GASTRICA.  327 

the  name  of  "Gastric  Aoacidity"  four  cases  belonging 
to  this  class  of  affections.  Eecently  D.  D.  Stewart ' 
has  written  a  very  valuable  paper  on  the  same  subject. 
Morbid  Anatomy. — There  exist  but  few  cases  of 
achylia  gastrica  in  which  autopsies  have  been  made. 


"^''SS^rM^M^ 


Fig.  47.— a  Small  Piece  of  Gastric  Jlucusa  (from  Patient  D.  S.,  with  Achylia  Gas- 
trica) Found  in  Wash-water  from  Stomach.  Only  few  glands  visible;  empty 
spaces  where  glands  had  previously  existed;  general  small  roimd-cell  infiltra- 
tion.   X  80. 

One  case,  observed  by  me,  showed  a  complete  atrophy 
of  the  gastric  tubules  (see  p.  166,  Fig.  38). 

As  to  the  question  whether  in  all  cases  of  achylia 
gastrica  there  necessarily  exists  an  anatomical  lesion 
(atrophy  of  the  glands)  or  not — i.e.,  whether  cases  of 
achylia  might  not  perhaps  occur  in  which  the  gastric 

'  D.   D.   Stewart :   American  Journal  of  the  Medical  Sciences, 
November,  1895. 


328 


DISEASES   OF   THE   STOMACH. 


P?^^^W^ 


mucosa  is  not  much  altered,  I  must  say  from  my  own 
experience  that  the  latter  is  frequently  the  case.  This 
is  the  reason  why  a  repair  of  this  condition  is  occasion- 
ally observed.' 

Etiology. — According  to  the  views  generally  enter- 
tained, achylia  gastrica  is  a  sequel  to  certain  severe 
chronic  catarrhal  conditions  of  the  stomach.  The 
more  recent  text-books  on  gastric  diseases   (Ewald, 

Boas,  Bouveret)  discuss 
this  affection  under  the 
head  of  "  Gastritis  Glan- 
dularis Chronica."  I 
certainly  believe  that 
such  an  origin  of  achylia 
gastrica  is  sometimes 
traceable.  The  cases  of 
chronic  gastric  catarrh 
in  which  the  acidity  is 
pretty  low  (10  to  20), 
^^  and  in  which  no  free 
^f;  ''^■~o^..^T'^  ^^^""^  "'  ^^"T^^  ^""T^  HCl  exists,  but  both  the 

(from  Patient  R.  H ,  with  Achylia  Gas-  ' 

trica):   no  glands  visible;  o,  general  small  jjiin'et  reactioU  and  reU- 

round-cell    infiltration;     b,    empty    spaces 

where  glands  had  previously  existed.    X  80.  net     are    prCSent,     Speak 

in  favor  of  this  view.  They  represent,  so  to  say,  tlie 
prodromic  stage  of  ach3'lia  gastrica.  Notwithstanding 
this  it  seems  to  me  more  than  probable  that  the  affec- 
tion in  question  may  develop  also  in  some  other  way 
(in  consequence  of  nervous  disturbances).  In  such 
instances  the  glandular  layers  of  the  stomach  need  not 
necessarily  be  greatly  altered,  although  it  appears  prob- 

*  Max  Einhorn  :  "  A  Further  Report  on  Achylia  Gastrica.  "  Medi- 
cal Record,  July  6th,  1895. 


ACHYLIA    GASTRICA.  329 

able  that  after  a  long  persistence  of  inactivity  of  the 
glands  these  may  begin  to  atrophy. 

Symptomatology . — With  regard  to  their  subjective 
complaints  patients  with  achylia  gastrica  may  be 
divided  into  three  groups : 

1.  Patients  without  any  subjective  symptoms  what- 
ever and  enjoying  perfect  euphoria: 

2.  Patients  presenting  a  variety  of  gastric  symp- 
toms associated  with  mild  intestinal  disturbances; 

3.  Patients  without  any  apparent  gastric  symptoms, 
but  with  severe  and  obstinate  intestinal  disturbances. 

Cases  belonging  to  the  first  group  are  quite  rare.  I 
therefore  do  not  deem  it  superfluous  to  describe  here 
such  a  case  without  any  gastric  or  intestinal  symptoms, 
which  possesses  the  further  interest  that  it  was  com- 
plicated with  rumination. 

Achylia  Gastrica,   Combined  icith  Rumination. — 

August  R ,  52  years  of  age,  carpenter,  was  always 

well  and  had  not  consulted  a  physician  for  the  last 
twenty  years.  Suffered  in  his  boyhood  from  frequent 
headaches,  cramps  in  the  abdomen,  and  diarrhoea 
until  his  twentieth  year.  The  patient  attributes  the 
griping  pains  in  his  abdomen  at  that  time  to  the  cir- 
cumstance of  growing  up  under  poor  and  miserable 
surroundings ;  as  a  rule  he  had  very  little  to  eat ;  from 
time  to  time,  however,  he  worked  in  the  country  with 
the  peasants,  where  he  had  plenty  of  good  things  to 
eat,  and  here  he  used  to  overload  his  stomach. 

As  a  boy  the  patient  partook  of  hardly  any  meat 
from  his  fifth  to  his  fourteenth  year  of  age ;  his  main 
nourishment  consisted  of  potatoes,  flour-soup,  bread, 
and  water — soup  only  now  and  then  :  of  meat  he  par- 
took only  when  occasionally  visiting  his  relatives.  He 
did  not  like  buttermilk  or  coffee. 


330  DISEASES   OF   THE   STOMACH. 

As  long  as  the  patient  can  recollect  he  often  brought 
up  the  food  from  the  stomach  into  the  mouth  about 
half  an  hour  after  the  meal,  chewing  it  and  swallow- 
ing it  again.  When  eating  cherries  he  w^as  in  the 
habit  of  swallowing  the  pits  also,  and  afterward, 
when  bringing  them  up  from  the  stomach  into  the 
mouth,  he  used  to  spit  them  out. 

This  bringing  up  of  the  food  the  patient  did  mainl}- 
when  feeling  well.  He  enjoyed  chewing  the  second 
time  as  much  as  w^hen  first  masticating  the  food. 
Often  the  food  would  come  up  in  morsels,  although 
the  patient  had  not  been  thinking  of  it  at  all.  He 
hardly  ever  vomited,  except  when  he  got  drunk — 
which  happened  twice  during  his  life — and  when  cross- 
ing the  ocean  on  a  trip  to  Germany.  He  eats  hastily, 
and  the  hard  substances  he  chews  w^ell  afterwards 
when  they  come  up  from  the  stomach. 

The  patient  can  ruminate  any  time  be  chooses,  ex- 
cept when  the  stomach  contains  but  very  little  or  is 
almost  empty.  In  ruminating  he  takes  care  to  con- 
ceal the  act  from  others ;  he  speaks  to  no  one  about  it, 
and  even  bis  wife  is  not  aware  of  his  habit. 

Present  Condition. — Strongly  built  man  of  short 
stature,  is  well  nourished,  with  good  panniculus  adi- 
posus ;  chest  organs  intact ;  stomach  dilated  ;  the  low^er 
margin  extending  to  one  finger's  width  above  the  navel. 
He  has  no  complaints  whatever,  enjoys  a  good  appe- 
tite, his  bowels  are  regular,  and  he  feels  well  in  every 
respect.  The  only  thing  which  strikes  him  as  being 
abnormal,  and  for  which  he  was  treated  for  some  time 
in  Germany  and  afterward  came  to  see  me,  is  his 
coated  tongue. 

October  27th. — One  hour  after  the  test  breakfast: 
Patient  spontaneousl}-  brings  up  a  small  quantity  of 
the  contents  of  his  stomach  (about  20  c.c).  With  the 
tube  likewise  only  a  small  quantity  can  be  obtained 


ACHYLIA   GASTEICA.  331 

The  roll  particles  are  not  minutely  minced  and  almost 
unchanged.  HCl  =  0;  acidity  =  2;  rennet  =  0;  pro- 
peptone  =  0;  peptone  =  0;  erythrodextrin  =  0. 

Meltzer's  swallowing  sounds:  Patient  drinks  water; 
at  the  first  swallow  a  sound  is  heard  immediately  at 
the  xyphoid  process  {Durchspritzgerdusch) ;  at  the  sec- 
ond swallow  (one  to  two  minutes  later)  a  sound  is 
heard  about  eight  seconds  afterward  {Diirclipress- 
gerdusch) ;  at  the  third  swallow  the  Durchspritzge- 
rmisch  is  heard  immediately ;  and  ten  seconds  later 
the  Dnrchpressgerdusch . 

I  had  the  opportunity  of  examining  the  patient  for 
three  months,  and  always  found  the  stomach  contents 
in  the  above-described  condition,  with  the  same  result 
of  chemical  analysis. 

The  history  of  this  case  seems  to  indicate  that  the 
abnormal  condition  of  the  stomach  developed  in  his 
early  youth ;  for  only  at  that  time  the  patient  had 
complaints,  whereas  later  on  he  had  no  disease  what- 
ever. This  would  show  clearly  that  achylia  gastrica 
may  exist  forty  years  without  endangering  the  vital 
functions  of  the  organism. 

The  second  group,  namely,  of  those  presenting  gas- 
tric symptoms,  comprises  the  greater  number  of  cases. 
The  symptoms  consist  of  loss  of  appetite,  of  a  sensa- 
tion of  fulness  or  pain  in  the  epigastric  and  gastric 
regions,  and  of  vomiting.  Occasionally  only  one  of 
these  symptoms  ma}^  be  present,  while  in  some  cases 
the  symptoms  mentioned  may  appear  alternately. 
Headaches  are  frequently  met  with,  and  constipation 
of  a  mild  character  is  also  more  or  less  the  rule. 

The  following  may  be  considered  as  a  typical  case  of 
this  group ; 


332  DISEASES   OF   THE   STOMACH. 

Mrs.  G ,  aged  about  -45,  has  complained  of  her 

stomach  for  the  last  twelve  years.  She  is  almost  al- 
ways troubled  after  meals  with  pains  in  the  gastric 
and  epigastric  regions.  Appetite  poor.  Bowels  in- 
clined to  be  constipated.  Vomiting  appears  very  sel- 
dom. Patient  had  lost  considerably  in  weight  during 
the  first  years  of  her  ailment;  thereafter  her  weight 
remained  stationary.  In  1891  she  visited  Carlsbad, 
but  her  condition  did  not  improve  any. 

Present  Condition. — Patient  of  small  stature  and 
quite  thin.  Panniculus  adiposus  somewhat  thin. 
Lips  and  cheeks  of  a  pale  color.  Tongue  not  coated. 
Chest  organs  normal.  Palpation  of  the  abdomen  re- 
veals the  absence  of  any  tumor.  The  epigastric  re- 
gion is  sensitive  on  pressure,  but  not  exactly  painful. 
A  splashing  sound  can  be  produced  to  about  three  fin- 
gers' width  below  the  navel.  The  urine  does  not  con- 
tain either  sugar  or  albumin. 

October  27th,  1892. — Examination  of  the  stomach 
one  hour  after  Ewald's  test  breakfast:  HCl  =  0;  lac- 
tic acid  =  0 ;  acidity  =  6 ;  rennet  =  0 ;  biuret  reac- 
tion =  0;  erythrodextrin  =  0;  sugar  +  .  The  quan- 
tity of  the  gastric  contents  is  not  large,  and  there  is  a 
very  small  amount  of  liquid.  The  bread  particles  are 
not  minute.     No  mucus. 

October  30th. — When  fasting,  stomach  empty. 

January  8th,  1893.' — Examination  of  the  stomach 
one  hour  after  Ewald's  test  breakfast:  HCl  =  0;  lac- 
tic acid  =  0 ;  acidity  =  4 ;  rennet  =  0  ;  pepsin  =  0 ; 
biuret  reaction  =  0 ;  erythrodextrin  =  0 ;  sugar  +  . 

During  the  year  1893  several  other  examinations  of 
the  gastric  contents  were  made,  with  the  same  ana- 
lytical data  as  just  mentioned. 

The  third   group,   without    gastric    symptoms  but 


ACHYLIA   GASTRICA.  333 

with  intestinal  disturbances,  forms,  according  to  my 
experience,  at  least  one-fifth  of  all  the  cases  of  achylia 
gastrica.  In  this  group  there  may  be  either  no  gastric 
disturbances  whatever  or  very  slight  ones  (as,  for  in- 
stance, occasionally  slight  pressure  in  the  gastric  re- 
gion— or  belching).  The  appetite  is  either  normal  or 
somewhat  increased.  The  principal  symptom  in  most 
of  these  cases  is  obstinate  diarrhoea,  or  diarrhoea  al- 
ternating with  periods  of  constipation.  Some  of 
these  cases  present  symptoms  similar  to  those  met 
with  in  diabetes:  constant  thirst,  frequent  micturition, 
extreme  weakness,  great  loss  of  flesh;  in  some,  how- 
ever, these  symptoms  are  less  marked,  or  there  may 
exist  merely  a  feeling  of  weakness  and  lack  of  energy. 
The  following  case  is  a  good  representative  of  this 
group. 

Solomon  S ,    57^  years  of  age,  always  enjoyed 

good  health  until  August,  1892,  when  he  had  a  severe 
attack  of  dysentery ;  he  was  confined  to  the  bed  for 
over  three  weeks  and  felt  afterward  extraordinarily 
weak.  Since  that  time  the  patient  has  had  attacks  of 
severe  diarrhoea  (much  mucus,  sometimes  blood  in  the 
passages)  every  two  to  three  weeks.  This  diarrhoea 
used  to  alternate  with  constipation.  From  August  to 
October,  1892,  the  patient  lost  forty  pounds  in  weight. 
From  that  time  on  he  felt  weak  and  miserable  and 
complained  of  thirst.  This  condition  has  since  re- 
mained unchanged,  and  he  complains  at  present  prin- 
cipally of  extreme  weakness,  of  intense  thirst,  and  of 
very  weakening  diarrhoeal  attacks. 

Present  Condition. — Color  of  lips  and  cheeks  very 
pale,  anaemic.  Tongue  furred  with  a  whitish  coat. 
Chest  organs  intact.     The  stomach  extends  to  one  fin- 


334  DISEASES   OP  THE   STOMACH. 

ger's  width  below  the  navel.  A  splashing  sound  can 
be  easily  produced  in  the  gastric  region.  There  is  no- 
where any  tumor.  There  are  no  sensitive  spots  dis- 
coverable in  the  abdoraen.  The  knee  reflex  is  present. 
The  in-ine  contains  neither  sugar  nor  albumin. 

Patient  was  treated  for  some  time,  at  first  with  in- 
jections into  the  bowel  (tannic  acid  2.0  to  a  quart  of 
water  once  daily),  thereafter  with  the  administration 
of  peptonate  of  iron.  These  means,  however,  failed  to 
be  of  any  benefit  whatever;  the  tired  feeling  and 
weakness  persisted,  and  the  frequent  attacks  of  diar- 
rhoea likewise  remained  unchanged. 

November  21st,  ISO-i. — Examination  of  the  stomach 
one  hour  after  Ew^ald's  test  breakfast :  HCl  =  0 ;  acid- 
ity =  2  ;  lactic  acid  =  0 ;  rennet  =  0 ;  pepsin  =  0 ;  bi- 
uret reaction  =  0 ;  erythrodextrin  =  0 ;  sugar  +  . 
Quantity  of  liquid  very  small ;  the  bread  particles  not 
minute;  no  admixture  of  mucus. 

November  23d, — When  fasting,  stomach  empty. 
Achylia  gastrica  is  diagnosticated,  and  the  patient 
treated  with  intragastric  faradization.  The  diet  is  ar- 
ranged in  such  a  manner  that  it  does  not  contain  very 
much  meat,  and  is  instead  rich  in  food  taken  from  the 
vegetable  kingdom. 

After  two  weeks  of  this  treatment  the  sensation  of 
weakness  w-as  no  longer  felt.  Patient  began  to  look 
better.  His  cheeks  had  a  red  color,  the  bowels  were 
regular,  and  the  troublesome  sensation  of  thirst  that 
formerly  was  so  annoying  disappeared. 

December  17th. — Examination  of  the  stomach  one 
hour  after  Ewald's  test  breakfast:  HCl  =  0,  of  neu- 
tral reaction  ;  biuret  reaction  =  0 ;  rennet  =  0 ;  pepsin 
~  0 ;  erythrodextrin  =  0 ;  sugar  +  .  Small  quantity 
of  fluid ;  the  bread  particles  not  minute;  no  mucus. 

Patient  asserts  that  he  feels  well ;  he  can  walk 
great  distances  without  feeling  tired. 


ACHYLIA    GASTRIC  A.  335 

December  20th. — One  and  a  half  hours  after  the  test 
breakfast :  stomach  empty. 

December  31st. — Patient  takes  one  glassful  of  milk; 
one  hour  afterward  he  takes  a  glassful  of  water,  and 
his  stomach  is  directly  faradized  for  ten  minutes. 
Then  the  gastric  contents  are  obtained  by  means  of  a 
tube;  they  consist  of  uncurdled  milk  diluted  with  wa- 
ter and  are  of  neutral  reaction. 

Patient  was  examined  at  various  times  in  January 
and  February,  1895,  and  there  was  always  found  a 
complete  absence  of  gastric  juice.  The  absoriDtion  of 
the  stomach  was  examined  by  means  of  the  potassium 
iodide  test,  and  the  iodine  could  be  detected  in  the  sa- 
liva after  a  lapse  of  eleven  minutes.  Patient's  health 
was  and  has  remained  thus  far  in  very  good  state;  his 
appetite  is  fair,  bowels  regular,  and  stools  well 
formed ;  no  attacks  of  diarrhoea. 

April  loth,  1895. — Patient  has  gained  ten  pounds 
in  weight. 

January,  1S96. — Patient  is  in  perfect  health  and 
has  gained  forty  pounds  in  weight. 

While  the  subjective  complaints  are  thus  of  quite  a 
manifold  nature  and  may  often  be  entirely  absent, 
particularly  as  regards  the  stomach,  the  objective 
symptoms  are  always  alike  and  show  the  following 
peculiarities.  One  to  one  and  a  half  hours  after 
Ewald's  test  breakfast:  1.  The  pieces  of  roll  are  not 
minutely  minced  and  unchanged.  2.  The  reaction  is 
very  weakly  acid  or  neutral,  usually  the  acidity  is  4. 
3.  Hydrochloric  acid  is  not  present.  4.  Lactic  acid  is 
either  absent  or  present  in  traces  and  can  be  discov- 
ered only  after  a  thorough  shaking  with  ether.  5. 
Neither  propeptone  nor   peptone  is  present.     6.   The 


336  DISEASES   OF   THE   STOMACH. 

tests  for  the  pepsin  and  rennet '  ferments  give  nega- 
tive results.  7.  The  stomach  contents  do  not  smell 
bad,  and  do  not  otherwise  give  the  appearance  of  de- 
composition. S.  Absence  of  mucus.  L».  The  quanti- 
ty of  liquid  found  in  the  stomach  of  these  patients  one 
hour  after  the  test  breakfast  is  remarkably  small. 
Aside  from  the  fluids  soaked  in  and  around  the  parti- 
cles of  bread  there  is  hardly  any  liquid  at  all.  The 
gastric  contents  thereby  acquire  a  peculiar,  character- 
istic appearance,  and  look  different  from  what  they 
do  in  other  affections  of  the  stomach. 

The  small  amount  of  fluid  in  the  gastric  contents 
of  patients  with  achylia  may  be  explained  in  the  follow- 
ing way :  Besides  the  water  (or  tea)  ingested  into  the 
stomach  with  the  test  meal,  there  is  no  addition  of 
juice  (or  liquid)  during  the  stay  of  food  in  this  organ. 
As  the  more  liquid  chyme,  as  a  rule,  leaves  the  stom- 
ach quicker  than  the  more  solid  substances,  these 
latter  alone  will  then,  after  a  while  (about  one  hour 
after  Ewald's  test  breakfast),  be  found  present. 

The  motor  function  of  the  stomach  is  as  a  rule  not 
impaired  or  slackened  ;  in  some  of  the  cases  it  is  rather 
somewhat  hastened  (Solomon  S ). 

The  absorption  faculty  of  the  stomach  is,  according 
to  my  experience,  not  in  any  way  retarded. 

Course. — This  disease  runs  a  very  protracted  course; 
cases  in  which  the  stomach  resumes  secretion  after  a 
cessation  of  several  years  are  very  rare.  I  have  had 
only  one  case  of  this  kind  under  observation.  As  a 
rule,  the  subjective  symptoms  can  be  greatly  amelio- 
rated or  entirely  removed  by  prolonged  rational  treat- 

'  The  rennet  zymogen,  however,  may  still  be  found  present. 


ACHYLIA    GASTRICA.  337 

ment,  while  the  objective  symptoms  of  achylia  remain 
unchanged. 

Diagnosis. — To  arrive  at  a  diagnosis  of  achylia  gas- 
trica  repeated  examinations  of  the  gastric  contents  are 
required  for  the  detection  of  the  above-mentioned 
characteristic  points. 

The  points  of  differential  diagnosis  between  achylia 
gastrica  and  cancer  of  the  stomach  have  been  de- 
scribed under  the  latter  affection  (p.  283)  and  are 
therefore  omitted. 

Prognosis. — The  prognosis  of  cases  of  achylia  gas- 
trica is  good  quoad  vitam,  a  view  which  I  have  repre- 
sented in  several  papers  and  which  is  now  generally 
accepted  by  most  writers.  The  small  intestine  per- 
fectly replaces  the  digestive  work  of  the  stomach,  and 
the  organism  is  not  only  enabled  to  maintain  its  equi- 
librium but  also  to  gain  in  weight. 

Treatment. — Therapeutic  measures  will  be  indicated 
only  in  cases  presenting  subjective  symptoms. 

The  treatment  w^ill  have  to  be  carried  out  in  the 
two  following  directions :  1.  To  stimulate  the  mechan- 
ical action  of  the  stomach.  2.  To  arrange  the  diet  in 
such  a  way  that  the  food  is  easily  accessible  for  the 
intestinal  digestion. 

The  first  point  is  best  achieved  by  stimulating  the 
stomach,  as  by  lavage  and,  principally,  direct  faradi- 
zation of  the  organ.  In  some  of  the  cases  I  have  not 
employed  any  medicaments  whatever,  and  in  others  I 
have  administered  condurango  or  nux  vomica. 

In  reference  to  diet,  it  is  of  utmost  importance  to 
see  that  the  food  is  broken  into  very  minute  particles 
or  can  be  easily  divided  by  chewing.     For,  on  the  one 


338  DISEASES   OF  THE   STOMACH. 

hand,  all  kinds  of  meat  are  in  no  way  altered  in  the 
stomach  and  reach  the  intestine  in  the  shape  in  which 
they  entered  the  cardiac  orifice ;  on  the  other  hand, 
the  starchy  substances  contained  in  the  vegetable  food 
cannot  become  converted  into  maltose  so  long  as  the 
albuminous  membrane  occluding  them  has  not  been 
opened. 

In  the  stomach  of  these  patients  starch,  as  such, 
when  accessible  to  the  action  of  ptyalin,  undergoes 
conversion  into  sugar  very  rapidly. 

Vegetable  food  is,  as  a  rule,  here  very  well  borne. 
Strained  pea  and  bean  soups  may  be  highly  recom- 
mended on  account  of  their  richness  in  albumin. 
Kumyss  or  matzoon,  or  sometimes  bonny-clabber  well 
beaten  with  a  spoon,  or  plain  milk  with  the  addition 
of  bread  or  crackers  with  butter,  are  highly  advan- 
tageous. Meats  are  to  be  allowed  only  in  small  quan- 
tities, best  well  hashed  and  broiled,  or  the  white  part 
of  chicken.  Brain,  sweetbread,  fish,  and  raw  oysters 
are  very  suitable.  Id  the  grave  cases  it  is  advanta- 
geous to  administer  meat  powder  '  (two  to  three  table- 
spoonfuls  or  even  more,  pro  die,  in  soup  or  milk). 

The  usual  beverages,  as  tea,  coffee,  cacao  with  milk 
and  sugar,  besides  small  quantities  of  beer  or  stout, 
may  be  allowed. 

Outline  of  Diet  in  Achylia  Gastrica. 

Calories. 

8  A.M. :  oatmeal  with  cream,  150  gm.,      .         .         .  395 
cacao  with  milk,  200  gm.,    .         .         .         .135 

'  Meat  powder  can  be  prepared  in  the  following  manner :  Raw 
lean  meat  is  cut  into  thin  slices  and  dried  on  a  glass  plate  on  the 
stove  for  about  two  or  three  hours,  then  pounded  in  a  mortar  and 
ground  twice  in  a  coflFee-mill. 


ACHYLIA   GASTKICA. 


339 


Calories. 

toasted  bread,  60  gm.,  .  .  .  .  .135 
butter,  20  gm., 163 

12  M.:  pea  soup,  200  gm., 190 

scraped  meat  (broiled)  or  fish,  100  gm.,  .  213 
baked  or  mashed  potatoes,  50  gm.,  .  .  63 
spinach  or  turnips,  50  gm.,  .  .  .  .82 
wheaten  bread,  60  gm.,  ....  135 
butter,  20  gm., 163 

6  P.M. ;  two  eggs  (soft-boiled  or  scrambled),  .  .  160 
farina  with  milk,  200  gm.,  ....  432 
wheaten  bread,  60  gm.,  ....  135 

butter,  20  gm., 163 

tea,  200  gm,  (milk,  30  gm. ;  sugar,  10  gm.),     60 

9  :  30  P.M. :  kumyss,  200  gm. ;  crackers,  30  gm. ; 
butter,  10  gm. ;  or,  instead,  a  sandwich  with 
cream  cheese  or  caviar,  or  sardines  and 
beer, 323 

2,9ir 

Here  also,  as  in  all  other  chronic  disturbances  of 
the  digestive  tract,  it  will  be  of  importance  to  pay  at- 
tention not  only  to  the  quality  but  also  to  the  quan- 
tity of  food  taken.  And  the  greatest  stress  must  be 
laid  upon  the  injunction  that  a  sufficient  quantity  of 
food  is  taken.  It  is  always  preferable  to  have  the  pa- 
tient partake  of  too  large  a  quantity,  of  food  rather 
than  too  small  a  quantity,  in  consequence  of  which  a 
condition  of  subnutrition  is  so  often  established. 

When  the  intestine  has  adapted  itself  to  the  greater 
amount  of  work  and  the  nutrition  is  maintained  on  a 
well-regulated  basis,  achylia  gastrica  need  not  cause 
any  trouble  whatever,  and  the  patient  may  enjoy  per- 
fect euphoria. 


CHAPTER  XL 

FUNCTIONAL      DISEASES      WITH      VARIABLE 
LESIONS.  —  Continued. 

Ischochymia. 

Definition. — An  affection  characterized  by  the  con- 
stant presence  of  food  in  the  stomach,  even  in  the  fast- 
ing state.  There  is  always  a  retardation  or  retention 
of  chyme  in  the  organ. 

General  Remarks. — The  term  "clinical  dilatation 
of  the  stomach,"  as  is  well  known,  is  applied  by  the 
majority  of  authors  to  a  condition  in  which  there  is 
stagnation  of  food  in  the  stomach.  Taken  in  its  true 
sense,  however,  the  word  "dilatation  of  the  stomach," 
or  "ectasia  ventriculi,"  refers  merely  to  the  dimen- 
sions of  the  organ.  This  explains  the  frequent  mis- 
understandings caused  by  these  expressions.  Some 
speak  of  dilatation  of  the  stomach  as  soon  as  the  limits 
of  this  organ  are  found  enlarged ;  others,  however, 
only  in  those  instances  where  there  are  found  rem- 
nants of  food  in  the  morning  in  the  fasting  condition. 
Rosen  bach,'  therefore,  suggested  the  term  "motor  in- 
sufficiency of  the  stomach,"  to  designate  that  condition 
in  which  the  transportation  of  food  from  the  stomach 
into  the  small  intestine  is  at  fault.  In  an  article  re- 
cently published.  Boas*  expresses  the  opinion  that  the 

■Rosenbach:  Volkmann's  Sammlung  klin.  Vortrage,  No.  153. 
1878. 

2  Boas:  Deutsche  med.  Wochenscbr.,  1894,  No.  28,  p.  576. 


ISCHOCHYMIA.  oil 

terms  "dilatation  of  the  stomach"  and  "ectasia  ven- 
triculi"  should  not  be  used  at  all,  and  suggests  the  term 
"gastric  insufficiency  of  the  first  and  second  degrees" 
instead.  The  first  degree  corresponds  to  the  atonic 
condition,  the  second  to  the  stagnation  of  food.  Al- 
though, like  Boas,  I  am  fully  convinced  of  the  impor- 
tance of  differentiating  between  cases  of  stagnation  of 
food  and  those  in  which  the  transportation  of  the 
chyme  is  only  slightly  retarded,  I  do  not,  however,  be- 
lieve that  we  ought  to  discard  the  expression  "dilata- 
tion of  the  stomach,"  or  that  the  proposed  term, 
"  gastric  insufficiency  of  the  first  and  second  degrees" 
is  well  selected. 

"Dilatation  of  the  stomach"  is  a  term  applied  to  the 
condition  of  the  volume  of  the  stomach,  and  signifies 
an  enlargement  of  its  dimensions.  Such  conditions 
not  only  do  exist,  but  are  an  every-day  occurrence. 
There  is,  therefore,  no  reason  for  discarding  the  term 
"dilatation  of  the  stomach."  Whether  this  enlarge- 
ment of  the  dimensions  of  the  stomach  has  been  due 
to  physiological  or  pathological  processes,  or  whether 
it  creates  abnormal  conditions  or  not,  will  have  to  be 
investigated  in  every  individual  case. 

The  term  "insufficiency"  or  "mechanical  (motor)  in- 
sufficiency of  the  stomach,"  signifying  a  retardation 
in  the  transportation  of  the  food  from  the  stomach 
into  the  intestine,  appears  to  me  ill  chosen ;  for  the 
word  "insufficiency,"  or  "mechanical  insufficiency  of 
the  stomach,"  does  not  clearly  point  out  the  condition 
caused  by  the  transportation  of  chyme  from  the  stom- 
ach into  the  intestines.  Moreover,  the  term  "me- 
chanical insufficiency  of  the  stomach"  means  that  the 


342  DISEASES   OF  THE   STOMACH. 

fault  for  the  non-transiDortation  of  food  lies  in  the 
stomach,  which  is  not  the  case  in  most  instances. 

Analogous  to  the  expression  ^'ischuria/*  which  sig- 
nifies an  abnormal  collection  or  stagnation  of  urine  in 
the  bladder,  without  giving  the  cause  of  this  condi- 
tion, the  word  "'ischochymia'- '  might  be  applied  in 
order  to  designate  an  undue  stagnation  of  chyme  in 
the  stomach."  Thus  " ischochymia"  will  embody  a 
complex  of  symptoms  without  stating  the  cause.  The 
latter  will  have  to  be  discovered  and  further  deter- 
mined in  each  case. 

Symptomatology. — Ischochymia  may  last  either  a 
short  period  of  time  (a  few  days  to  one  week)  or  it 
may  become  chronic  or  stationary. 

Acute  ischochymia  is  occasionally  found  as  a  result 
of  an  acute  inflammatory  process  of  the  gastric  mu- 
cosa in  consequence  of  gross  errors  in  diet  and  the  like. 
Ischochymia,  then,  although  quite  rarely,  may  develop 
alarming  symptoms  and  may  even  lead  to  a  fatal  is- 
sue. Several  such  instances  have  been  reported  un- 
der the  heading  of  acute  dilatation  of  the  stomach  by 
Hunter,"  Frankel,"  and  Boas,^  the  case  of  the  latter 
author  ending  in  recovery.  Whether  acute  ischo- 
chymia is  due  to  a  paralysis  of  the  gastric  muscles,  or 
whether  it  is  caused  by  a  spasmodic  contraction  of  the 
pylorus,  is  as  yet  undecided.  Probably  both  condi- 
tions exist.     In  these  instances  it  appears  that  nothing 

'  Ischochymia,  from  t(T;i:E(v=detain,  and  ;fi'(/(5f=chyme. 
-See  Max  Einhorn  :  "Diagnosis  and  Treatment  of  Stenosis  of  the 
Pylorus."     Medical  Record,  .January  19th,  1895. 
'  ^Hunter:  Medical  Record,  1889. 
■*A.  Frankel :  Deutsche  med.  Wochenschr.,  1894,  No.  7. 
^.J.  Boas:   Deutsche  med.  Wochenschr.,  1894,  No.  8. 


ISCHOCHYMIA.  343 

passes  from  the  stomach  into  the  duodenum;  auy- 
thing  which  is  taken  in  the  way  of  food  or  drink  col- 
lects in  the  stomach  and  distends  it.  The  presence  of 
gastric  juice  may  still  further  increase  the  amount  of 
liquid  within  the  organ,  and  in  this  way  aggravate 
the  condition.  The  prolonged  stagnation  of  chyme 
within  the  stomach  gives  rise  to  manifold  processes  of 
decomposition  and  fermentation.     Vomiting   usually 


Fig.  49.— a  Specimen  of  Chyme  Obtained  from  the  Stomach  in  the  Fasting  Condi- 
tion (from  a  Patient  with  Isehochymia  [H.]).  showing  (a)  vegetable  ceUs, 
C6)  partly  digested  muscle  fibres,  (c)  starch  grains,  (cZ)  fat,  (e)  yeast  cells, 
baciUi  and  cocci. 

occurs  and  brings  temporary  relief.  The  direct  cause 
of  an  eventual  fatal  issue  is  quite  difficult  to  state. 
It  may  be  due  to  auto-intoxication  or  to  some  more 
direct  injury  to  the  vagus  nerve. 

Transient  isehochymia  may  appear  in  conditions 
in  which  the  muscles  of  the  stomach  are  weakened 
and  fail  to  do  their  work  properly,  or  in  a  begin- 
ning stenosis  of  the  pylorus.     In  both  instances  the 


344  DISEASES   OF   THE   STOMACH. 

ischochymia  is  only  slightly  marked — that  is,  while 
there  is  a  retention  of  some  food  in  the  stomach,  the 
greater  part  is  transferred  into  the  small  intestines. 
In  the  fasting  condition  the  amount  of  chyme  present 
in  the  stomach  is  not  large.  In  a  few  days  the  stom- 
ach, as  a  rule,  recuperates  and  by  more  energetic  ac- 
tion succeeds  in  accomplishing  its  work  properly,  that 
is,  transports  all  the  chyme  to  the  duodenum  during 
the  night. 

Constant  ischochymia  is  always  a  serious  trouble. 
Processes  of  fermentation  are  almost  constantly  present 
(Fig,  49).  It  is  here  that  the  occurrence  of  manifold 
gases  has  been  described ;  as,  for  instance,  sulphu- 
retted hydrogen,  hydrogen,  marsh  gas,  oxygen,  and 
carbon  dioxide.  In  some  of  these  patients  the  gas 
eructated  burns  with  a  flame  if  lighted  (Ewald). 
Very  often  it  is  possible  to  hear,  when  auscultating 
the  gastric  region  of  these  patients,  a  constant  bub- 
bling or  sizzling  sound,  arising  from  the  rapid  for- 
mation of  the  gas.  If  the  gastric  contents  of  such 
patients  be  obtained  and  put  in  a  cylinder,  one  can 
perceive  the  bubbles  of  gas  rising  to  the  surface.  The 
amount  of  gas  may  be  determined,  according  to 
Kuhn,'  by  placing  small  quantities  of  the  filtrate  in  a 
fermentation  tube  which  is  kept  at  blood  temperature 
for  several  hours. 

Chronic  ischochymia  is  almost  always  accompanied 
by  the  following  train  of  symptoms:  The  appetite  is 
frequently  poor,  although  at  times  it  may  be  abnor- 
tnally  increased.  The  sensation  of  thirst  is  usually 
augmented  and  in  some  cases  constantly  present,  and 

'  Kuhn  ;  Deutsche  med.  Wochenschr. ,  1892,  Nos.  49  und  50. 


ISCHOCHYMIA.  345 

the  patient  is  continually  tormented  with  a  feeling  of 
extreme  dryness  in  his  throat.  A  feeling  of  oppres- 
sion almost  always  exists,  which  at  times  may  alter- 
nate with  more  or  less  intense  pains.  The  eructation 
of  gas,  which  has  a  disagreeable  odor,  is  often  met 
with.  Vomiting  of  large  quantities  of  chyme,  in 
which  particles  of  food  from  previous  days  may  be 
recognized,  is  one  of  the  most  important  symptoms. 
The  vomiting  may  occur  once  or  twice  a  day,  or  once 
only  in  two  or  three  days.  There  are  very  few  cases 
in  which  the  bowels  work  regularly ;  as  a  rule,  the 
most  obstinate  constipation  is  found.  Emaciation  is 
present  in  almost  all  instances,  and  it  may  occasion- 
ally reach  such  a  degree  that  the  patient  literally 
looks  like  a  skeleton. 

In  the  advanced  stages  of  ischochymia,  the  quan- 
tity of  urine  voided  in  twenty-four  hours  is  greatly 
reduced,  and  may  sometimes  be  less  than  600  c.c. 

Etiology. — Ischochymia  is  due  to  a  diminished  mus- 
cular work  of  the  stomach,  or  to  stenosis  of  the  py- 
lorus, or  to  an  open  ulcer  within  or  very  near  the  py- 
lorus. In  the  latter  instances  a  spasmodic  contraction 
of  the  pylorus  takes  place. 

Course. — The  course  of  ischochymia  will  materially 
differ,  according  to  the  etiological  factors  causing  this 
condition.  Ischochymia  due  to  muscular  weakness  of 
the  organ  (atony)  may  occasionally  disappear  without 
medical  aid  and  is  in  most  instances  amenable  to  ra- 
tional treatment.  Ischochymia  due  to  stenosis  of  the 
pylorus  will  run  a  different  course,  according  to  the 
nature  of  the  stenosis.  If  the  latter  be  of  a  benign 
type  (hypertrophy  of  the  jDylorus  or  stricture  of  the  py- 


346  DISEASES   OF   THE   STOMACH. 

lorus  due  to  cicatricial  contraction)  there  are  at  first 
ameliorations  which  are  due  to  an  hypertrophy  of  the 
muscles  of  the  stomach  and  to  increased  compensatory 
action ;  frequently,  however,  the  symptoms  of  stenosis 
return  as  soon  as  the  pylorus  has  become  still  nar- 
rower, until  at  last  sufficient  compensation  cannot  he 
effected.  In  this  stage  the  only  means  of  saving  the 
life  of  the  patient  is  surgical  intervention  in  the  way 
of  establishing  a  larger  opening  between  the  stomach 
and  the  small  intestines,  which  may  be  done  either  by 
Heinecke-Mikulicz'  pyloroplasty  or  by  a  gastro-enteros- 
tomy. 

In  all  these  cases  a  radical  cure  can  thus  be  accom- 
plished. The  patients  then  gain  considerably  in 
weight,  have  no  pain,  no  digestive  troubles  whatever, 
and  can  attend  to  their  daily  vocations  in  life.  They 
all  feel  as  if  "new-born,"  if  I  may  be  permitted  to  use 
this  expression.  In  two  of  these  patients  I  convinced 
myself,  by  means  of  several  experiments,  of  the 
prompt  forwarding  of  the  contents  of  the  stomach  into 
the  intestines.  The  chemical  condition  was  not  mark- 
edly changed;  the  gastric  volume  in  the  two  patients 
was  not  appreciably  lessened  six  months  after  the  ope- 
ration. In  one  of  my  newly  observed  cases,*  however, 
there  was  a  marked  diminution  in  the  size  of  the 
stomach  two  months  after  the  gastro-enterostomy. 
If  the  stenosis  is  of  a  malignant  type,  then  the  course 
will  correspond  to  the  original  disease.  However,  it 
is  here  also  possible  to  relieve  the  symptoms  of  is- 
chochymia  by  an  early  gastro-enterostomy. 

'  Max  Einhorn  :  "  A  Fuitlier  Contribution  to  our  Knowledge  of 
Ischocliymia. "     Medical  Record,  June  19th,  1897. 


ISCHOCHYMIA.  347 

Before  taking  ujd  the  diagnosis,  we  may  consider 
some  symptoms  which  are  characteristic  of  the  just- 
mentioned  etiological  factors : 

IscJiochymia  due  to  Atony. — In  this  condition  the 
residue  of  chyme  found  in  the  stomach  in  the  fasting 
state  consists  of  some  liquid  and  fine  particles  of  food. 
Even  if  coarse  particles  of  food  (as,  for  instance,  as- 
paragus, spinach,  rice  grains  not  too  well  cooked, 
chestnuts,  and  the  like)  have  been  ingested  on  the  pre- 
vious day,  the  residue  of  these  substances  is  not  so 
very  much  pronounced,  while  in  ischochymia  due  to 
stenosis  of  the  pylorus  it  will  be  found  that  the  entire 
quantity  of  such  coarse  particles  of  food,  which  under- 
go no  changes  in  the  stomach,  will  remain  within  the 
organ.  In  atony  of  the  stomach  the  difSculty  merely 
lies  in  a  deficient  peristalsis  of  the  stomach,  i.e.,  the 
contents  are  not  sufficiently  jDushed  toward  the  py- 
lorus. But  whatever  reaches  this  outlet  can  pass 
without  much  inconvenience,  whether  it  be  very  fine 
or  whether  coarser  particles  be  present.  This  is  quite 
different  in  stenosis  of  the  pylorus,  for  here  the  main 
obstacle  is  the  narrowness  of  the  canal,  which  does 
not  permit  of  the  passage  of  coarser  particles  of  food. 
The  peristalsis  of  the  stomach,  even  if  the  muscles 
work  with  increased  activity,  is  here  without  much 
avail. 

As  cases  of  ischochymia  due  to  a  weakened  condi- 
tion of  the  muscular  action  of  the  stomach  are  quite 
rare,  the  following  case,  which  I  have  observed  very 
recently,  will  not  be  without  interest: 

Patient  H — — ,  aged  46  years,  had  been  suffering  for 
the   last   three  years  with  an  intense  burning  sensa- 


3-t8  DISEASES    OF    THE    STOMACH. 

tion,  beginning  at  the  pit  of  the  stomach  and  extend- 
ing all  the  way  up  through  the  oesophagus  to  the 
pharynx.  There  was  a  feeling  of  pressure  in  the  gas- 
tric region,  which  occasionally  alternated  with  pains. 
Besides,  the  patient  complained  of  belching  of  bad- 
smelling  gases,  which  were  very  disagreeable,  espe- 
cially to  his  wife  and  immediate  family.  His  appetite 
was  fair,  and  constipation  existed  only  in  a  slight  de- 
gree. His  weight  had  steadily  decreased  during  the 
last  three  years,  so  that  he  had  lost  over  fifty  pounds 
within  that  period.  The  examination  of  the  patient 
revealed  that  the  stomach  was  quite  enlarged;  a 
splashing  sound  extended  to  about  two  fingers'  width 
below  the  navel,  and  a  succussion  sound  could  be  eas- 
ily produced.  The  examination  of  the  stomach  in  the 
fasting  condition  revealed  the  presence  of  a  considera- 
ble quantity  of  chyme,  which  presented  all  the  signs 
of  marked  decomposition  (almost  fetid  odor,  presence 
of  sulphuretted  hydrogen  ;  microscopically,  each  speci- 
men was  full  of  micro-organisms,  yeast  cells,  and 
sarcinse) ;  free  hydrochloric  acid,  however,  was  pres- 
ent in  quite  normal  amounts.  After  a  thorough 
cleansing  of  the  organ,  the  patient  was  told  to  par- 
take of  light  (more  liquid)  food  during  the  day,  and 
for  supper  of  some  meat,  a  liberal  amount  of  rice,  not 
too  well  cooked,  and  some  bread. 

On  the  following  morning  the  patient  was  again 
examined  in  the  fasting  condition.  While  some  chyme 
was  present  in  the  stomach,  the  amount  of  rice  found 
was  very  small  indeed,  so  that  it  was  rather  difficult 
to  recognize  its  presence  with  certainty.  The  result 
of  this  observation,  combined  with  the  points  derived 
from  the  history  of  the  disease  (the  symptoms  steadily 
keeping  on  and  slowly  gaining  in  severity,  no  decided 
free  intermissions  of  long  duration),  seemed  to  point 
to  an  atonic  state  of  the  gastric  muscles,  rather  than 


ISCHOCHYMIA.  349 

to  stenosis  of  the  pylorus.  The  beneficial  results  of 
the  treatment,  which  was  based  on  this  view  (regu- 
lation of  diet,  four  or  five  meals  daily,  interdiction 
of  larger  amounts  of  liquids,  large  doses  of  bismuth, 
with  the  addition  of  small  doses  of  resorcin,  and  oc- 
casional lavage  of  the  stomach),  justified  the  conclu- 
sion that  the  diagnosis  was  correct.  The  patient 
after  a  few  weeks  felt  much  better,  lost  his  burning 
sensation,  while  the  stomach  in  the  fasting  condition 
was  now  found  empty,  and  only  after  the  ingestion  of 
a  very  large  supper  the  stomach  on  the  following 
morning  contained  a  small  quantity  of  chyme,  but 
not  smelling  badly.  After  three  months  the  patient 
had  gained  twelve  pounds  iii  weight,  and  is  steadily 
improving. 

Benign  Stenosis ^  of  the  Pylorus. — Only  rarely  can 
the  pylorus  be  palpated  as  a  small  oval  tumor  (of 
small  hen's  egg  size);  in  most  instances  the  pylorus 
cannot  be  felt.  All  cases  reveal  a  long  period  of  sick- 
ness (extending  from  two  to  fifteen  years),  in  which 
the  appearance  of  pain  plays  the  greatest  part.  Al- 
though at  first,  either  with  or  without  therapeutic 
aid,  there  appear  ameliorations,  these  periods  of  eu- 
phoria, however,  are  again  and  again  interrupted  by 
fresh  attacks  of  sickness.  They  constantly  become 
more  violent  and  of  longer  duration,  and  the  pains 
subside  only  after  an. artificially  induced  or  spontaneous 
vomiting  spell.  Still  later,  when  the  ischochymia  de- 
velops to  a  higher  degree,  not  even  vomiting  brings 
entire  relief,  and  the  patients  are  subjected  to  the 
greatest  pain  and  suffering.  They  emaciate  quickly, 
and,  if  there  is  no  radical  intervention  at  this  period, 
death  from  starvation  inevitably  eventuates. 


350 


DISEASES   OF   THE   STOMACH. 


The  following  two  cases  present  good  instances  of  a 
benign  stenosis  of  the  pylorus : 

Case  I. — Louis  L ,  40  years  of  age,  lawyer,  be- 
gan to  be  troubled  with  his  stomach  in  the  summer  of 


fprmr-x^ 


FiQ.  50.— Cross-section  of  a  Benign  Hypertrophied  Pylorus.    (From  the  writer's 

own  observation.)     X  60. 

1891.      The   patient  was   attacked  with   pains   after 
meals  during  a  period  of  ten  days,  when  this  symptom 


ISCHOCHYMIA.  351 

disappeared  suddeDly.  There  was  no  vomiting.  For 
six  months  the  patient  felt  well,  not  having  any  pains 
whatever;  he  noticed,  however,  that  he  became  tired 
quicker  than  heretofore.  In  the  winter  of  1892  (Feb- 
ruary) he  again  had  an  attack  of  pain,  lasting  more 
than  a  month.  During  this  attack  he  vomited  twice. 
He  felt  well  until  July,  when  he  had  a  fresh  attack  of 
pain  extending  over  two  to  three  weeks,  with  four 
vomiting  spells.  On  account  of  the  severe  pains  he 
could  not  lie  quietly,  but  had  to  walk  frequently  to 
and  fro  in  his  room.  In  December,  1892,  the  patient 
had  another  attack,  lasting  until  February,  1893.  He 
then  had  to  vomit  frequently  (nearly  every  other  day). 
He  had  never  vomited  any  blood.  Since  the  begin- 
ning of  the  sickness  his  bowels  were  constipated. 

On  January  2Tth,  1893,  Dr.  Charles  Simmons  called 
me  in  for  a  consultation  and  kindly  entrusted  me  with 
the  treatment  of  the  patient. 

When  I  first  saw  the  patient  he  presented  the  pic- 
ture of  a  very  sick  man  in  agonies  of  pain.  He 
looked  pale  and  emaciated;  he  asserted  that  he  had 
lost  about  forty  pounds  in  weight  since  the  beginning 
of  his  ailment,  and  complained  of  a  feeling  of  constric- 
tion in  the  abdomen  and  of  shortness  in  breathing ;  he 
further  complained  of  vomiting  large  quantities  of 
fluid,  and  of  obstinate  constipation.  During  the  last 
fourteen  days  the  patient  had  taken  large  doses  of 
opium ;  he  was,  however,  very  rarely  entirely  free 
from  pain. 

The  examination  of  the  chest  organs  did  not  reveal 
anything  abnormal.  Tongue  slightly  coated;  pulse, 
90;  temperature,  98°  F.  The  whole  abdomen  was 
more  or  less  bloated  and  quite  tense.  In  the  gastric 
region  no  splashing  sound  could  be  produced.  No  tu- 
mor could  be  felt.  The  fluid  which  the  patient  vom- 
ited a  few  hours  before  showed  many  blackish  flakes 


352  DISEASES   OF   THE   STOMACH. 

floating  in  it,  contained  a  great  quantity  of  free  HCl. 
gave  no  reaction  for  lactic  acid,  and  had  an  acid- 
ity =  90. 

Patient  was  instructed  to  have  a  light  meal  (well- 
scraped  meat,  oysters,  milk,  crackers)  every  two 
hours.  The  quantity  of  liquids  was  reduced,  and  he 
was  allowed  to  take  only  J  50  c.c.  at  a  time.  Besides, 
oil  clysmata  were  administered.  Under  this  treat- 
ment the  patient  felt  somewhat  better,  although  his 
ailment,  on  the  whole,  did  not  change.  On  January 
29th  he  was  instructed  not  to  take  any  food  after  his 
eight  o'clock  evening  meal  until  the  next  morning. 
On  January  30th,  at  8  A.M.,  when  fasting,  the  tube 
was  inserted  into  the  stomach  and  two  quarts  of  liquid 
withdrawn.  The  stomach  was  then  washed  with 
lukewarm  water.  Patient  felt  exceedingly  well  after 
this  lavage. 

The  withdrawn  gastric  liquid  was  analyzed ;  in  this 
sample  there  were  the  blackish  flakes  mentioned 
above.  The  examination  showed  :  HCl  + ;  acidity 
=  88;  lactic  acid  not  present;  peptone  + ;  propep- 
tone  +  ;  rennet  and  pepsin  +  ;  erythrodextrin  -j-. 

Microscopically,  no  particles  of  meat  can  be  found ; 
amylaceous  grains,  yeast  cells,  and  bacteria  are  present 
in  considerable  quantity.  Teichmann  's  test  for  blood 
shows  the  absence  of  hsemin. 

Thus  the  withdrawn  liquid  consisted  principally  of 
gastric  juice  and  of  remnants  of  food  taken  the  pre- 
vious day. 

February  1st,  1898,  at  10  p.m.,  the  stomach  of  the 
patient  was  thoroughly  washed  out.  During  the  night 
he  did  not  partake  of  anything,  and  on  February  2d. 
at  8  A.M.,  the  stomach  was  examined  with  the  tube, 
and  a  small  quantity  of  liquid  withdrawn  (150  c.c). 
The  examination  of  this  gastric  liquid  showed : 
ITCl  -\-  :  both  ferments  present;  acidity  =  70. 


ISCHOCHYMIA.  353 

The  patient  was  treated  with  lavage  for  another 
week.  He  felt  better  and  could  walk  outdoors.  The 
pains,  however,  persisted,  although  they  were  less  se- 
vere, and  the  stomach  was  never  empty  in  the  morning, 
but  contained  more  or  less  liquid  with  food  rem- 
nants. 

February  11th,  13th,  and  15th. — Intragastric  gal- 
vanization was  applied  without,  however,  materially 
improving  the  patient's  condition.  The  diagnosis  of 
benign  stenosis  of  the  pylorus  was  made  and  an  oper- 
ation strongly  recommended. 

Dr.  F.  Lange  undertook  the  operation  on  February 
22d.  The  pylorus  was  found  greatly  constricted. 
Heinecke-Mikulicz's  pyloroplasty  was  performed,  and 
after  a  month's  confinement  the  patient  left  the  clinic. 
Although  he  was  now  able  to  partake  of  a  more  va- 
ried and  coarse  diet  without  vomiting,  he  nevertheless 
constantly  complained  of  pains  and  had  to  resort  to 
opium. 

On  March  30th  the  stomach  was  examined  one  hour 
after  the  test  breakfast:  HCl  +  ;  no  lactic  acid; 
acidity  =  120,  no  remnants  of  food  from  the  previous 
day.  It  was  supposed  that  this  high  degree  of  acidity 
might  be  the  cause  of  the  pains.  The  patient  was 
therefore  instructed  to  take  half  a  teaspoonful  of  bi- 
carbonate of  soda  three  times  a  day,  two  hours  after 
meals.  This  worked  like  a  charm ;  the  pains  entirely 
disappeared  and  he  began  to  gain  rapidly  in  flesh 
After  six  months'  medication  with  the  soda  the  pa- 
tient discontinued  its  use  and  felt  perfectly  well  with- 
out it.  He  now  attends  to  his  business  and  has 
gained  seventy  pounds  since  the  operation. 

Case  II. — Mrs.  P.  L ,  43  years  of  age,  mother 

of  three  children.  Her  mother  died  of  cancer.  Pa- 
tient has  been  suffering  for  six  years.  The  ailment 
began  with  diarrhceal  trouble  lasting  for  two  years. 

23 


354  DISEASES   OF  THE   STOMACH. 

(Patient  is  unable  to  state  whether  the  stools  were  of 
dark  color.)  Since  four  years  cramps  in  the  stomach. 
The  pains  are  extremely  severe;  there  is  relief  after 
belching  or  flatus.  Never  had  any  jaundice.  For 
the  last  two  years  intense  burning  in  the  stomach 
with  frequent  vomiting.  Never  vomited  any  blood. 
During  the  night  the  jDains  are  extremely  severe  and 
disturb  slee^D.  Patient  during  last  months  lost  con- 
siderably in  weight  (about  thirty  pounds).  She  was 
referred  to  me  by  Dr.  Willy  Meyer  for  examination 
and  diagnosis. 

Present  Condition. — Chest  organs  intact.  Palpa- 
tion of  the  abdomen  reveals  a  small  cylindrical  tumor, 
of  the  size  of  an  Qgg,  situated  to  the  right  of  the  na- 
vel. This  tumor  is  easily  movable  in  all  directions 
and  has  a  smooth  surface.  A  splashing  sound  can  be 
produced  in  the  gastric  region  from  one  to  two  fingers' 
width  below  the  navel.  The  gastric  region  is  not 
painful  to  pressure.     The  liver  is  not  enlarged. 

After  lavage  the  patient  is  examined  with  the  gas- 
trodiaphane;  the  stomach  is  found  considerably  en- 
larged and  occupying  a  low  position. 

On  the  following  day  the  patient  is  examined  with 
the  tube  one  hour  after  a  cup  of  tea  without  bread 
(the  patient  being  in  the  fasting  condition  with  the 
exception  of  the  tea).  The  stomach  contained  about 
300  c.c.  of  a  slightly  greenish  liquid  (presence of  bile), 
in  which  were  only  a  few  remnants  of  food  (several 
bread  particles)  from  the  previous  day.  The  analysis 
showed  :  HCl  +  ;  acidity  =  42 ;  free  HCl  =  24;  lactic 
acid  =  0. 

The  patient  was  then  treated  for  a  week  with  lav- 
age and  chloral  hydrate  at  the  New  York  Post-Grad- 
uate  Hospital;  there  was,  however,  no  material  im- 
provement in  her  condition. 

On  a  subsequent    examination    one    and   one-half 


ISCHOCHYMIA.  355 

hours  after  Ewald's  test  breakfast:  HC1+  ;  acidity  — 
50;  no  lactic  acid.  The  obtained  gastric  contents 
amounted  from  300  to  400  c.c.  and  contained  food  from 
previous  days;  for  instance,  rice,  which  had  been 
taken  on  the  previous  night,  and  several  grape-skins, 
which  had  been  taken  three  days  before.  This  time 
no  bile  could  be  detected. 

The  diagnosis  (of  benign  stenosis  of  the  pylorus) 
was  made  and  the  patient  operated  on  by  Dr.  Willy 
Meyer.'  After  opening  the  abdomen  the  tumor,  which 
proved  to  be  the  thickened  pylorus,  was  resected. 
The  duodenum  was  then  inserted  into  the  stomach  by 
means  of  Murphy's  button.  The  patient  passed  an 
undisturbed  convalescence,  evacuated  the  button  in 
her  stools  during  the  third  week,  and  has  since  been 
well.  She  has  gained  twenty  pounds  and  has  had  no 
pains  whatever. 

The  resected,  highly  thickened,   and   stiff  pylorus 
could  not  be    macroscopically   distinguished    from    a 
cancerous  organ ;  the  microscopical  examination,  how- 
ever, showed  that  it  was  merely  an  hypertrophied  py 
lorus.'^ 

Malignant  Stenosis  of  the  Pylorus  or  Cancerous 
Stenosis. — Stenosis  of  the  pylorus  due  to  carcinoma  is 
of  frequent  occurrence,  and  is  developed  sooner  or  la- 
ter in  the  course  of  most  cancers  of  the  stomach 
appertaining  to  this  region.  Cases  in  which  the  diag- 
nosis is  made  at  an  early  period  are  most  suitable  for 
surgical  interference.  When  possible,  the  tumor 
should    be    resected;     otherwise    gastro-enterostomy 

^  Heinecke-Mikulicz's operation  could  not  be  done  in  this  case. 
(1)  on  account  of  suspicion  of  cancer ;  (2)  because  the  lumen  was 
too  narrow  and  the  thickening  of  the  walls  of  the  pylorus  too  con- 
siderable. 

2  The  wall  of  the  pylorus,  after  specimen  was  preserved  in  alcohol 
for  about  nine  months,  measured  in  thickness  li  cm. 


356  DISEASES   OF   THE    STOMACH. 

should  be  performed.  An  operation  appears  to  me  to 
be  always  indicated  when  there  exists  ischochymia  for 
some  time,  and  either  a  tumor  is  felt  or  else  the  diag- 
nosis of  cancer  of  the  pylorus  can  be  made  by  other 
deductions — unless  the  tumor  has  assumed  too  exten- 
sive dimensions  or  the  patient  be  too  weak  to  stand 
an  operation.  Assuredly  one  can  in  many  cases  give 
great  benefit  for  a  more  or  less  prolonged  period  of 
time,  and  the  sooner  the  greater.  Of  the  considerable 
number  of  cases  of  cancerous  stenosis  of  the  pylorus 
which  I  have  seen  during  the  past  five  years,  eight 
have  been  operated  upon.  In  only  one  was  resection 
of  the  pylorus  practised ;  in  all  others  gastro-enteros- 
tomy  was  performed  by  well-known  surgeons  of  this 
city.  One  patient  died  during  the  first  week  after 
the  operation.  The  remaining  seven  lived  from  two 
months  to  a  year. 

All  cases  of  cancerous  stenosis  reveal  a  more  or  less 
short  period  of  illness' (five  months  to  one  and  a  half 
years  at  the  utmost)  and  show  considerable  ischo- 
chymia. In  most  instances,  with  but  few  exceptions, 
a  gastric  tumor  can  be  palpated.  In  some  of  the 
cases  the  position  of  the  tumor  can  be  accurately  de- 
termined with  the  gastrodiaphane.  By  means  of 
transillumination,  it  can  be  ascertained  whether  the 
tumor  occupies  the  greater  or  lesser  curvature  of  the 
stomach.  I  append  the  drawings  of  two  cases  as 
viewed  with  the  aid  of  the  gastrodiaphane  (Figs.  51 
and  52).     Both  patients  had  been  operated  on  by  Dr. 

'  There  are,  however,  exceptions  to  this  rule.  Thus  a  cancer 
which  has  developed  on  the  basis  of  an  ulcer  may  give  a  long  period 
of  disease. 


ISCHOCHYMIA. 


dOY 


F.  Kammerer,  at  the  German  Hospital,  and  the  diag- 
nosis as  to  position  of  the  tumor  was  found  to  be 
correct.  Most  cases  show  the  absence  of  free  HCl  and 
the  presence  of  lactic  acid,  although  in  some  instances 
free  HCl  is  present  in  considerable  quantities  and 
lactic  acid  absent,  as  the  following  case  demonstrates: 


Fig.  51.— Resiilt  of  Gastrodiaphany  in  Patient  K  X ,-sritti  Tumor  in  the  Gastric 

Region,    a,  The  transilluminated  zone;  6,  the  dotted  spot  slightly  translucent  on 
pressure;  c,  the  black-colored  spot  remains  dark  even  on  pressure. 

March  9th,   lS9i.— Oscar  F ,  32  years  of  age, 

silk  manufacturer,  always  robust  and  healthy,  has 
been  suffering  for  the  past  six  or  seven  months  from 
digestive  troubles  which  have  been  constantly  increas- 
ing. They  consist  principally  of  pain,  and  for  the  last 
four  months  also  of  frequent  spells  of  vomiting.  Pa- 
tient has  lost   forty  pounds  in   weight.     Bowels   not 


358 


DISEASES    OF   THE   STOMACH. 


materially   impaired.      Poor    appetite.      Patient  has 
never  vomited  any  blood. 

Present  Condition. — Patient  looks  thin  and  cachec- 
tic. Lips  and  cheeks  are  extremely  pale.  Chest  or- 
gans intact.  Palpation  of  the  abdomen  shows  pain- 
fulness  on  pressure  in  the  gastric  region  and  an 
egg-sized  tumor  somewhat  to  the  right  and  above  the 


Fig.  52.— Result  of  Gastrodiaphany  in  Patient  M.  R ,  vith  Tumor  in  the  Gas- 
tric Region,  a,  The  transilhiminated  zone;  6,  the  dotted  spot  slightly  translucent 
on  pressure;  c,  the  black-colored  spot  remains  dark  even  on  pressure. 

navel.  This  tumor  is  not  especiall}'"  painful  on  pres- 
sure, presents  a  smooth  surface,  and  is  easily  mova- 
ble. A  splashing  sound  can  be  produced  in  the  gas- 
tric region  extending  to  two  fingers'  width  above  the 
symphysis. 

March  9th,  at  6  p.m. — Patient  had  taken  a  glass- 
ful of  milk  at  10  a.m.  and  had  had  nothing  since;  it 


ISCHOCHYMIA,  359 

was  therefore  eight  hours  after  his  last  meal.  Ex- 
amination by  means  of  the  tube  revealed  the  presence 
of  two  pints  of  chyme.  The  latter  showed  a  brownish 
color,  contained  small  particles  of  casein,  and  various 
other  food -stuffs.  HCl  + ;  no  lactic  acid;  acidity  = 
118;  free  HCl  =  94. 

Patient  is  instructed  to  take  with  his  supper  rice, 
milk,  and  crackers. 

March  10th. — When  fasting,  two  pints  of  chyme  are 
withdrawn  from  the  stomach.  The  chyme  presents 
a  brownish  color  and  contains  food  from  previous 
days- — rice,  particles  of  bread,  and  casein.  Microscop- 
ically: yeast  cells,  granules  of  starch,  sarcinse,  bacte- 
ria, brown  pigment.  Chemically  :  HCl  +  ;  no  lactic 
acid ;  acidit}^  =  112  ;  peptone  +  ;  propeptone  +  ;  ren- 
net +  ;  erythrodextrin  +  little ;  achroodextrin  +  much. 

March  12th. — The  stomach  is  examined  in  the  fast- 
ing condition  and  the  same  results  are  obtained  as  on 
the  10th. 

The  high  degree  of  ischochymia  and  the  presence  of 
a  tumor  in  the  pyloric  region  pointed  with  certainty 
to  a  stenosis  of  the  pylorus.  It  was  questionable,  how- 
ever, whether  the  process  was  a  benign  or  a  malig- 
nant one.  Whereas  the  chemical  condition  of  the 
gastric  contents  pointed  toward  a  benign  stenosis,  the 
large  size  of  the  tumor  and  the  relatively  short  period 
of  sickness  (six  to  seven  months)  answered  more  to 
the  history  of  a  malignant  growth. 

After  a  consultation  with  Dr.  F.  Lange,  we  both 
were  of  the  opinion  that  we  had  to  deal  here  with  a 
cancerous  stenosis  of  the  pylorus.  The  high  degree 
of  ischochymia  appeared  to  necessitate  surgical  inter- 
ference, which  should  consist  in  either  resection  of 
the  pylorus  or  in  gastro-enterostomy. 

Patient  was  operated  on  by  Dr.  Lange,  on  March 
16th,  1894;  the  tumor  was  found  (macroscopically)  to 


360  DISEASES    OF    THE    STOMACH. 

be  a  cancer,  and  conld  not  be  resected  on  account  of 
the  numerous  adhesions,  principal!}'  with  the  colon. 
Gastro-enterostomy  was  established,  and  in  about  a 
month's  time  patient  was  able  to  leave  the  clinic  and 
partake  of  a  great  variety  of  food.  Soon,  however, 
regurgitation  of  bile  into  the  stomach  appeared,  and 
a  short  while  afterward  ''peristaltic  restlessness''  of 
this  organ  also  developed.  Both  conditions  made  the 
patient  feel  very  uneasy. 

April  19th. — Patient  was  examined  one  hour  after 
Ewald's  test  breakfast.  There  was  a  considerable 
amount  of  bile  in  the  gastric  contents,  which  did  not 
contain  any  food  from  the  previous  day.  Chemically: 
HCl  =  0;  no  lactic  acid  ;  acidity  =  22. 

Diagnosis. — In  cases  of  ischochymia  due  to  stenosis 
of  the  pylorus,  benign  as  well  as  malignant,  symp- 
toms of  vomiting  '  and  pain  are  almost  always  pres- 
ent, in  connection  witb  a  more  or  less  considerable 
loss  of  weight.  This  condition,  however,  is  best  rec- 
ognized by  the  examination  of  the  stomach  by  means 
of  the  tube  when  fasting.  I  usually  instruct  the  pa- 
tient to  have  at  his  supper,  on  the  night  preceding  the 
examination,  besides  soup,  meat,  and  bread,  some 
rice,  as  this  latter  is  very  easily  recognized  and  as  a 
rule  is  retained  in  the  stomach  when  the  pylorus  is 

'  Vomiting  may  sometimes  be  absent,  notwithstanding  that  ischo- 
chymia has  already  developed.  I  at  present  have  under  observation 
a  patient  with  carcinoma  pjlori  (with  clearly  palpable  tnmor),  who 
has  been  ailing  for  the  last  six  months.  Tlie  patient  has  never 
vomited  nor  has  he  had  mucli  pain.  His  complaints  merely  refer 
to  loss  of  appetite  and  obstinate  constipation.  The  examination  of 
the  stomacli  iu  the  fasting  condition  always  reveals  the  presence  of 
chyme  (coarse  food-stuffs  are  principally  found).  Although  the 
patient,  living  on  a  more  regulated  diet,  has  gained  six  pounds 
within  the  last  month,  nevertheless  the  ischochymia  remained  un- 
changed. 


ISCHOCHYMIA. 


361 


stenosed.  For  this  examination  the  expression  meth- 
od alone  is  not  always  sufficient.  Whenever  no 
chyme  is  withdrawn  by  this  method,  it  is  necessary  to 
wash  out  the  stomach.  In  these  cases  food  is  then 
continually  found  in  the  stomach.  Dilatation  of  the 
stomach  is  almost  always  present ;  the  organ  occasion- 
ally extends  from  the  margin  of  the  ribs  far  down  to 
the  symphysis. 

Differential  Diagnostic  Points. 


Duration    of    ill- 
ness. 

Course  of  the  dis- 
ease. 

Tumor 


Benign  stenosis  of  pylorus. 


Long  duration  of  illness 
(two  to  fifteen  years) . 

Long  intervals  without 
pain,  or  periods  of  per- 
fect euphoria. 

As  a  rule  absent 


Malignant  stenosis  of  pjlorus. 


Short  duration  of  illness 
(five  months  to  one  and 
one-half  years). 

No  periods  of  perfect  eu- 
phoria, but  constant 
and  gradual  aggrava- 
tion of  the  symptoms. 

Present  in  most  cases. 


Condition  of  Gastric  Contents. 


Benign  stenosis  of  pylorus. 

FreeHCl 

Lactic  acid 

Acidity 

Rennet 

Present  in  the  great  ma- 
jority of  cases. 

Absent  in  the  great  ma- 
jority of  cases. 

Always  increased 

Always  present 

Odor 

Unpleasant,  disagreeable 

Malignant  stenosis  of  pylorus. 


Nearly  always  absent. 

As  a  rule,  present. 

Fluctuates    between    30 

and  90. 
Varies. 
Very  frequently  fetid. 


In  the  following  I  shall  describe  several  symptoms 
which,  w^hen  present,  are  very  valuable,  but  whose 
absence  does  not  militate  against  the  existence  of  py- 
loric stenosis.     These  symptoms  are : 

1,  The  dilated  or  abnormally  large  stomach. 

2.  The  thickened  and  readily  palpable  pylorus. 


362  DISEASES    OF    THE    STOMACH, 

3.   The  peristaltic  restlessness  of  the  stomach, 
•i.  The  fermentation  products. 

1.  The  abnormal  size  of  the  stomach  is  pathogno- 
monic only  if  the  organ  occupies  nearly  the  entire 
lower  section  of  the  abdomen,  and  contains  over  three 
or  four  litres  of  fluid.  Such  stomachs  are  frequently 
met  with  in  old  cases  of  stenosis  of  the  pylorus,  and 
their  presence  at  once  awakens  the  suspicion  of  a  nar- 
rowing of  the  pylorus;  before  this  diagnosis  can  be 
made,  however,  the  presence  of  ischochymia  must  be 
determined.  In  this  country  considerable  weight  has 
been  placed  upon  this  symptom;  yet  the  absence  of 
this  diagnostic  sign  should  not  lead  us  astray,  for  it 
is  our  aim  to  make  the  diagnosis  of  pyloric  stenosis  as 
early  as  possible,  while  the  pronounced,  at  once  per- 
ceiDtible  dilatation  of  the  stomach  develops  only  in  the 
course  of  time. 

2.  If  it  is  possible  by  means  of  palpation  to  map  out 
the  pylorus  as  a  smooth,  oval  tumor,  and  if  ischochy- 
mia is  present  and  the  disease  has  lasted  over  one  and 
a  half  or  two  years,  we  can  with  certainty  make  a 
diagnosis  of  benign  pyloric  stenosis. 

3.  Peristaltic  restlessness  of  the  stomach  is  fre- 
quently found  in  cases  of  benign  as  well  as  of  malig- 
nant stenosis  of  the  pylorus.  Inasmuch  as  the  peri- 
staltic restlessness  of  the  stomach  but  very  rarely 
occurs  as  a  pure  neurosis,  this  symptom  is  of  great 
significance  for  the  recognition  of  stricture  of  the 
pylorus,  the  more  so  as  an  examination  for  this  pur- 
pose (simple  inspection  of  the  abdomen  in  the  recum- 
bent position)  is  not  attended  with  any  difficulty. 

The  presence  of  this  symptom  in  connection  with 


ISCHOCHYMIA.  363 

the  existence  of  ischochymia  speaks  in  favor  of  nar- 
rowing of  the  pylorus,  and  against  simple  relaxation 
of  the  gastric  muscular  coat;  the  absence  of  this 
symptom  is  of  no  consequence. 

tt.  Fermentation  products  (formation  of  lactic  acid 
or  gases  in  the  stomach)  are  observed  almost  con- 
stantly in  all  cases  of  ischochymia.  Commonly,  one 
or  the  other  kind  of  fermentation  is  present,  that  is, 
either  formation  of  lactic  acid  or  formation  of  gases. 
The  lactic  acid  is  found  in  the  stomach  in  cases  in 
which  the  secretion  of  hydrochloric  acid  is  consider- 
ably diminished,  while  the  development  of  gas  is  en- 
countered in  cases  in  which  there  is  an  abundant 
secretion  of  gastric  juice.  These  points,  which  have 
been  especially  emphasized  by  H.  Strauss,^  I  can  com- 
pletely confirm  on  the  ground  of  my  own  experience. 

These  fermentation  products  may  be  absent,  how- 
ever, notwithstanding  the  presence  of  pyloric  stenosis, 
if  the  stomach  has  been  treated  in  a  rational  manner, 
that  is,  has  been  washed  out  several  times. 

The  constant  or  frequent  occurrence  of  small  quan- 
tities of  bile  in  the  stomach  does  not  in  my  experience 
militate  against  the  existence  of  a  narrowing  of  the 
pylorus;  on  the  other  hand,  it  appears  to  ine  to  point 
to  a  firm  rigidity  of  this  orifice,  in  consequence  of 
which  the  latter  is  never  completely  closed." 

Among  the  more  recent  auxiliary  measures  which 
are  available  in  arriving  at  a  diagnosis,  the  gastro- 
scope  has  been  recently  employed  by  Eosenheim  and 
Kelling.     In  my  opinion  there  is  no  doubt  that  this 

1  H.  Strauss  :  Zeitchr.  f.  klin.  Medicin,  1895. 

2  Max  Einhorn  :  "A  Further  Contribution  to  Our  Knowledge  of 
Ischochymia, "  I.  c. 


364  DISEASES   OP   THE   STOMACH. 

instrument  has  a  great  future,  although  at  present  it 
has  not  been  generally  utilized. 

A  protracted  atony  of  the  stomach  may  at  times 
produce  ischochymia;  it  is  then,  however,  not  con- 
stantly found  and  disappears  soon  after  the  regula- 
tion of  diet  and  rational  treatment.  The  same  may 
be  said  of  grave  forms  of  chronic  gastric  catarrh. 
Here  also  ischochymia  is  liable  to  develop  under  fa- 
vorable conditions.  The  symptom,  however,  disap- 
pears after  a  few  washings  of  the  stomach.  In  this 
way  I  believe  that  these  two  conditions  (atony  of  the 
stomach  and  chronic  gastric  catarrh)  can  be  distin- 
guished without  difficulty  from  stenosis  of  the  pylorus, 
and  can  give  no  cause  whatever  for  mistakes. 

Treatment. — In  the  treatment  of  ischochymia  it  is 
necessary,  first  of  all,  to  ascertain  the  cause  of  the 
stagnation  of  food  in  the  stomach. 

If  this  be  due  to  a  far-advanced  stenosis  of  the  py- 
lorus, or  to  a  commencing  occlusion  of  this  opening 
malignant  in  its  nature,  surgical  interference  (pyloro- 
plastic  operation,  pylorectomy,  or  gastro-enterostomy) 
is  indicated.  If  we  have  to  deal,  however,  with  com- 
mencing benign  stenosis  of  the  pylorus,  or  a  genuine 
relaxation  of  the  muscular  coat  of  the  stomach,  pal- 
liative treatment  should  first  be  given  a  trial,  and  in 
the  event  of  its  failure  an  operation  is  demanded. 

The  palliative  treatment  in  the  milder  cases  consists 
in  the  employment  of  a  fluid  or  semifluid  diet  (milk 
soups,  with  finely  ground  farina,  meat  broths  with 
eg,g,  egg  and  milk)  lavage  of  the  stomach  in  fasting 
condition,  followed  by  spraying  with  a  one-per-mille 
solution  of  nitrate  of  silver,  and  in  the  administration 


ISCHOCHYMIA.  365 

of  medicaments  which  prevent  fermentation.  Among 
these  may  be  used  benzonaphthol,  salol,  bismuth,  and 
resorcin.     I  frequently  give: 

I^  Eesorcin 4. 0 

Bismuth,  subnit 20. 0 

Aq.  dest 200.0 

S.     One  tablespoonful  in  a  wineglassful  of  water  three  times 
daily,  half  an  liour  before  meals. 

In  severe  cases  (frequent  vomiting,  violent  pains, 
intense  burning  sensations)  it  is  advisable  to  keep  the 
patients  in  bed  for  about  three  weeks,  and  to  nourish 
them  for  five  days  exclusively  per  rectum  (besides 
the  nourishing  enema  rectal  injections  of  water,  as 
recommended  by  Unverricht,  are  of  great  benefit  when 
thirst  is  present  and  the  amount  of  urine  decreased) 
and  then  slowly  and  gradually  adopt  a  miik  diet,  as 
in  ulcer  of  the  stomach — in  this  condition,  however, 
much  more  cautiously  and  slowly. 

Thus,  for  example,  on  the  sixth  day  I  give  only  two 
tablespoonfuls  of  milk  every  hour,  on- the  seventh  day 
three  tablespoonfuls,  on  the  eighth  day  four  table- 
spoonfuls,  etc.,  until  I  have  reached  100  c.c.  every 
hour;  then  I  give  200  c.c.  every  two  hours,  and  in- 
crease to  300  c.c.  On  every  other  morning  I  de- 
termine by  washing  out  the  stomach  in  the  fasting 
condition  whether  it.  is  empty. 

In  this  manner  it  is  frequently  possible  to  adapt  the 
stomach,  first  to  a  light,  and  later  to  a  heavier  diet. 
The  patients  then  increase  gradually  in  weight  and 
appear  completely  well.  Yet  they  cannot  be  regarded 
as  entirely  healthy,  because  we  must  be  constantly 
prepared  for  a  recurrence  of  the  old  affection. 


366  DISEASES   OF   THE    STOMACH. 

Moreover,  in  cases  in  which  it  is  not  possible  to 
remove  the  ischochymia  by  palliative  measures,  the 
patient  may  sometimes  maintain  a  comfortable  ex- 
istence under  use  of  regular  washings  out  of  the 
stomach  and  the  maintenance  of  a  light  and  rather 
fluid  diet.  Such  patients,  however,  are  menaced  by 
many  dangers  and  can  enjoy  but  few  of  the  luxuries 
of  life,  and  for  this  reason  the  clinician  should  insist 
that  an  operation  is  to  be  regarded  as  the  only  correct 
procedure. 

In  benign  stenosis  of  the  pylorus  the  application  of 
massage  (ten  minutes  twice  daily)  to  the  gastric  region 
can  be  warmly  recommended.  Likewise  the  admin- 
istration of  alkalies  in  existing  hyperacidity,  and  the 
application  of  the  galvanic  current  when  there  are 
severe  pains  may  be  profitably  tried. 

Cancerous  stenosis  of  the  pylorus  hardly  admits  of 
any  treatment.  Condurango  given  when  there  is 
anorexia,  and  chloral  hydrate  (a  tablespoonful  of  a 
three-per-cent  .solution  every  two  to  three  hours) 
when  pains  exist,  as  has  been  recommended  by  Ewald, 
are  the  most  reliable  and  efficient  medicaments. 

In  ischochymia  due  to  atony  of  the  gastric  muscles 
the  treatment  should  consist  of  lavage,  direct  faradi- 
zation of  the  stomach,  and  the  administration  of 
frequent  but  light  meals. 

Complications. 

Tetany. — The  occurrence  of  tonic  and  clonic  spasms 
in  the  flexors  of  the  arms,  in  the  muscles  of  the  calf, 
and  in  the  muscles  of  the  abdomen  as  a  complication 
of   "dilatation   of   the   stomach"    (ischochymia)    was 


ISCHOCHYMIA.  367 

first  pointed  out  by  E,  Neumann '  and  shortly  after- 
ward by  Kussmaul/  Frequently  the  muscles  of  the 
face,  of  the  jaws,  and  of  the  neck  are  likewise  affected 
by  the  spasmodic  contractions.  The  eyes  are  turned 
upward  and  occasionally  emprosthotonus  of  short  dura- 
tion occurs.  The  crampy  contractions  are  painful; 
consciousness  is  either  undisturbed,  partly  disturbed, 
or  entirely  absent.  In  one  of  Kussmaul's  cases,  which 
was  published  by  Gassner,  ^  the  attacks  had  a  dis- 
tinctly epileptiform  character.  Several  cases  of  this 
complication,  which  have  been  described  mostly  un- 
der the  name  of  tetany,  have  been  published  by 
Leven,*  Dujardin  Beaumetz,"  Hanot,  Miiller,''  Ger- 
hardt,'  Eenvers,"  Bouveret  and  Devic,'Ewald,"  Albu," 
Boas,"  and  Fleiner.''  Real  tetany  is  characterized  by 
the  sudden  appearance  of  mostly  bilateral  tonic  con- 
tractions of  the  muscles,  beginning  at  the  fingers 
and  toes  and  progressing  thence  centripetally.  The 
flexor  muscles  are  principally  affected,  and  the  hand 
usually  assumes  a  position  which  has  been  charac- 
terized by  Trousseau  as  the  obstetrical  hand.     Only 


'  E.  Neumann  :  Deutsche  Klinik,  1861. 

2  Kussmaul:  Deutsch.  Arch.  f.  klin.  Med.,  1869,  Bd.  vi. 

"  Gassner  :  Inaug.  Dissert. ,  Strassburg,  1878. 

"* Leven:  Gaz.  med.  de  Paris,  1881,  p.  646. 

^Dujardin  Beaumetz  :  L'Union  medic. ,  1884,  Nos.  15  and  18. 

"Mtiller  :  Charite  Annalen,  Bd.  13,  1886. 

'Gerhardt:    Berl.  klin.   Wochenschr.,   1886,    No.  36,    and   1888, 
No.  4. 

^  Renvers  :  Gesellschaf t  der  Charite  Aerzte,  1887. 

"  Bouveret  et  Devic  :  Rev.  de  medecine,  1892,  p.  48. 
'"  Ewald  :  Berl.  klin.  Wochenschr. ,  1894,  No.  2. 
'^Albu:  Berl.  klin.  Wochenschr.,  1894,  No.  2. 
I'Boas:  loc.  cit.,  107. 
^^Fleiner:  Arch.  f.  Verdauungskrank. ,  Bd.  i.,  Heft  3. 


368  DISEASES   OF   THE   STOMACH. 

in  rare  instances  are  the  extensor  muscles  also  af- 
fected. As  a  rule,  the  knees  are  bent  and  the  toes 
turned  downward,  while  the  heel  is  turned  upward 
and  somewhat  outward  (pes  equiuus).  The  muscles 
of  the  femur  and  the  thigh  are  only  very  rarely  in- 
volved. The  duration  of  the  attacks  may  vary  from 
five  minutes  to  several  hours.  The  following  symp- 
toms, which  exist  for  some  time  after  the  attacks, 
are  characteristic  of  tetany : 

1.  Compression  of  the  main  nerves  or  blood-vessels 
of  the  affected  extremities  for  one  to  two  minutes  will 
produce  an  attack  (Trousseau) ;  2.  The  electrical 
irritability  of  the  nerves  and  muscles  is  greatly  in- 
creased (Erb) ;  3.  The  mechanical  irritability  of 
many  nerves  of  the  extremities,  and  especially  of  the 
facialis,  is  increased.  Tapping  with  a  finger  in  the 
region  of  the  facial  nerve  produces  quick  contractions 
of  the  corresponding  muscles.  Kneading  of  the  face 
from  top  to  bottom  evokes  contractions  of  the  sub- 
jacent muscles  (Chvostek). 

The  prognosis  of  tetany  is  quite  bad.  In  the  cases 
collected  by  Bouveret  and  Devic  there  was  a  mortality 
of  seventy  per  cent. 

It  seems  that  this  complication  is  of  quite  rare  oc- 
currence, for  all  the  cases  mentioned  in  literature 
scarcely  exceed  thirty.  Tetany -like  convulsions  and 
epileptiform  attacks  with  loss  of  consciousness  are  met 
with  far  more  frequently.  According  to  my  experi- 
ence, the  latter  complications  occur  not  only  in  cases 
of  chronic  ischochymia,  but  also  in  other  affections  of 
the  stomach. 


ISCHOCHYMIA.  369 

.  Thus  I  have  observed  one  case  in  a  man,  28  years 
old,  who  suffered  for  a  great  many  years  from  a 
chronic  gastric  catarrh.  In  August,  1895,  during  a 
hot  spell,  he  was  obliged  to  drink  large  quantities  of 
ice-water.  At  that  time  he  began  to  suffer  from 
attacks  of  tetany,  alternating  with  epileptiform  con- 
vulsions and  loss  of  consciousness.  During  an  attack 
of  tetany  the  patient  would  notice  that  his  arms  and 
legs  became  contracted  against  his  will  and  would 
remain  in  this  condition  for  about  ten  minutes,  he 
being  perfectly  conscious,  but  unable  to  change  the 
assumed  position  of  the  affected  extremities. 

The  epileptiform  attacks  would  begin  with  a  pre- 
monitory stage  of  pain  in  the  gastric  region  and  a 
restless  condition  which  would  last  only  a  short  while. 
Thereupon  the  patient  would  lose  his  consciousness 
entirely  and  convulsions  of  all  the  muscles  in  the  body 
would  ensue.  He  would  remain  in  this  state  from 
twenty  to  forty  minutes,  would  frequently  bite  his 
tongue,  and  after  awakening  usually  had  no  idea  of 
what  had  happened.  The  patient  had  such  attacks  of 
either  tetany  or  epileptiform  convulsions  once  or  twice 
a  week,  and  felt  utterly  prostrated  for  a  day  or  two 
after  their  occurrence.  He  also  complained  of  a  very 
disagreeable  taste  in  the  mouth  between  the  attacks. 
On  examining  the  stomach  in  the  fasting  condition, 
I  found  that  it  was  perfectly  empty.  One  hour  after 
a  test  breakfast  free  hydrochloric  acid  was  present, 
but  the  degree  of  acidity  was  somewhat  diminished. 
Under  lavage  and  a  general  tonic  treatment,  the 
patient's  condition  improved  and  the  attacks  became 
milder  in  form  and  appeared  at  much  longer  inter- 
vals ;  thus  for  a  period  of  six  weeks  the  patient  had 
no  attacks  whatever.  The  attacks  sometimes  occurred 
without  any  apparent  cause,  sometimes,  however, 
they  could  be  referred  to  some  gross  dietetic  error; 

24 


370  DISEASES   OF   THE   STOMACH. 

thus,  for  instance,  the  patient  once  took  a  very  large 
piece  of  salted  herring  with  bread  and  cheese  at  twelve 
o'clock  at  night  before  retiring.  He  awoke  at  two 
and  called  his  brother,  who  slept  in  the  adjoining 
room,  telling  him  of  his  restless  condition  and  of  the 
painful  sensation  within  his  stomach,  and  a  few  min- 
utes later  was  seized  with  a  severe  convulsive  attack, 
which  lasted  for  half  an  hour,  and  during  which  he 
again  severely  bit  his  tongue. 

I  have  observed  a  similar  case  of  epileptiform  at- 
tacks in  which  there  was  likewise  no  ischochymia,  but 
hyperchlorhydria  and  erosions  of  the  stomach.  In 
this  case,  however,  the  attacks,  as  a  rule,  appeared 
after  an  accidental  overloading  of  the  stomach,  alco- 
holic drinks  apparently  playing  a  great  part  therein. 
In  a  third  case  I  likewise  noticed  epileptiform  attacks 
in  a  lady  of  forty  years  of  age,  who  suffered  from 
chronic  ischochymia,  due  to  a  benignant  stenosis  of 
the  pylorus. 

The  prognosis  of  these  epileptiform  attacks  seems 
to  be  far  more  favorable  than  that  of  real  tetany, 
for  in  none  of  the  three  cases  mentioned  have  the  at- 
tacks thus  far  resulted  in  a  fatal  issue. 

With  regard  to  the  etiology  of  either  tetany  or  the 
epileptiform  attacks  accompanying  severe  gastric  dis- 
orders, three  theories  have  been  expounded:  1.  One 
theory  has  been  given  by  Kussmaul,  explaining  the 
symptoms  of  tetany  and  similar  conditions  by  the 
great  loss  of  fluids  to  which  the  system  has  been  sub- 
jected, for  this  condition  is  most  frequently  found  in 
patients  who  have  vomited  for  a  long  time  and  in 
this  way  lost  a  great  deal  of  liquid,  in  consequence  of 


ISCHOCHYMIA.  371 

which  the  blood  has  been  much  thickened,  while  the 
nerves  and  all  other  tissues  have  become  thoroughly 
dry.  The  thirst  which  is  met  with  in  these  patients 
and  the  greatly  diminished  urinary  excretion  speak 
in  favor  of  this  view.  This  theory  has  lately  gained 
a  warm  supporter  in  Fleiner,  who  pointed  out  that  in 
most  of  these  conditions  of  stenosis  of  the  pylorus,  be- 
sides the  slight  quantity  of  liquid  which  is  able  to 
pass  from  the  stomach  into  the  small  intestines,  there 
is  often  a  state  of  hypersecretion,  owing  to  which 
abundant  quantities  of  gastric  juice  are  poured  into 
its  cavity.  The  latter  circumstance  increases  the  great 
deficiency  of  water  in  the  system. 

2.  The  second  theory,  advanced  by  Germain  See,' 
explains  these  tonic  and  clonic  convulsions  as  a  reflex 
action  from  the  nerves  of  the  stomach.  Friedrich 
Miiller  is  also  in  favor  of  this  view,  for  the  two  follow- 
ing reasons :  First,  tetany  is  occasionally  met  with  in 
cases  in  which  there  is  no  considerable  loss  of  fluid, 
as  for  instance  in  cases  of  intestinal  worms.  Secondly, 
Miiller  was  able  to  produce  such  an  attack  of  tetany 
in  one  of  his  patients  by  striking  his  epigastrium. 

3.  The  third  theory  explains  tetany  and  similar 
conditions  on  the  basis  of  auto-intoxication.  In  cases 
of  ischochyrnia,  many  processes  of  fermentation  and 
decomposition  exist,  and  these  give  rise  to  the  produc- 
tion of  toxic  elements,  .which  are  liable  to  give  rise  to 
the  above-described  symptoms.  Gerhardt,  Baginski,^ 
Paliard,'  Loeb,*  Bouveret  and  Devic,  Ewald,  Heim,' 


*  Germain  See  :  Bull,  de  I'Acad.  de  med., 
^Bagiuski:  Arch.  f.  Kinderlieilk.,  Bd.  vii.,  1886. 
spaliard:  Rev.  de  medic,  1888,  p.  406. 
^Loeb:  Dentsch.  Arch.  f.  klin.  Med.,  Bd.  46,  p.  98. 
*Heim:  Inaug.  Diss.,  Bonn,  1893. 


372  DISEASES   OF   THE   STOMACH. 

Albu,  Scblesinger/  and  Kulneff '  are  all  firm  believers 
in  tbis  auto-intoxication  tbeory.  Bouveret  and  Devic, 
and  likewise  Kulneff,  have  been  able  to  obtain  from 
the  gastric  contents  of  patients  with  chronic  ischochy- 
mia  by  Brieger's  method  (extraction  with  alcohol  and 
precipitating  with  chloride  of  mercury)  toxic  products 
of  the  diamine  group.  Ewald  and  Jacobson,  and  later 
Albu,  have  obtained  from  the  urine  of  a  patient  af- 
fected with  tetany  an  alkaloidal  substance  (the  picrin 
salt).  This  substance  usually  appeared  in  the  urine 
during  the  attacks  of  tetany  only  and  not  during  the 
intervals.  Bouveret  and  Devic  are  of  the  opinion 
that  the  toxic  products  develop  much  quicker  in  cases 
of  hyperchlorhydria  if  alcoholics  have  been  indulged 
in.  Although  the  auto-intoxication  theory  seems  to 
be  the  most  plausible,  its  verification  remains  to  be 
demonstrated. 

'  Schlesinger :  Berl.  klin.  Wochenschr. ,  1894,  No.  9. 
2 Kulneff :  Berl.  klin.  Wochenschr.,  1891,  No.  44 


CHAPTER  XII. 

ABNORMAL  CONDITIONS  WITH  REFEEENCE 
TO  THE  SIZE,  SHAPE,  AND  POSITION  OF 
THE  STOMACH. 

Abnormalities  in  The  Size  of  the  Stomach. 

In  the  normal  state,  the  size  or  capacity  of  the 
stomach  varies  within  wide  limits,  and  this  is  more 
marked  in  pathological  conditions.  The  following 
figures  of  capacity  were  obtained  by  Ziemssen  '  as  the 
result  of  a  large  number  of  post-mortem  examinations 
of  the  stomachs  of  persons  of  about  the  same  size  who 
during  life  had  never  manifested  signs  of  digestive 
troubles.  The  largest  stomach  of  these  held  1,680  c.c. 
(or  fifty-six  ounces) ,  the  smallest  250  c.  c.  (eight  ounces) ; 
the  other  figures  ranged  between  these  limits.  While 
some  years  ago  any  stomach  of  very  large  size  was 
considered  as  diseased,  Ewald  first  pointed  out  that  the 
organ,  no  matter  how  great  its  capacity,  may  still  be 
able  to  work  perfectly  and  satisfactorily.  He  therefore 
suggested  that  an  acquired  or  congenital  large  stomach 
with  normal  functions  should  be  designated  as  "me- 
gastria.''^  A  very  large  stomach  causing  manifest 
digestive  disturbances  is  generally  spoken  of  as  a 
dilated  stomach  (dilatation  of  the  stomach,  gastrec- 
tasia).  The  most  extensive  degrees  of  gastric  dilata- 
tion are  found  in  cases  of  obstruction  of  the  pylorus. 

'  Ziemssen,  cited  from  C.  A.  Ewald  :  "Diseases  of  the  Stomach," 
p.  110. 


374  DISEASES   OF   THE   STOMACH. 

Angustatio  ventriculi  denotes  an  extremely  small 
stomach.  In  very  marked  degrees  of  this  condition 
the  stomach  may  have  a  capacity  of  hardly  an  egg  in 
size,  and  may  appear  even  narrower  than  the  duode- 
num (Haller).  Angustatio  ventriculi  is  generally 
found  in  most  cases  of  oesophageal  or  cardiac  strictures 
(principally  cancerous) ;  occasionally,  however,  it  oc- 
curs alone  in  cirrhosis  ventriculi. 

Abnormalities  in  the  Shape  of  the  Stomach. 

The  shape  of  the  stomach  is  occasionally  found  al- 
tered, caused  by  cicatricial  changes  after  extensive 
ulcers.  The  hour-glass  form  is  one  which  gives  rise 
to  grave  disturbances  and  can  frequently  be  recognized 
during  life.  Inflation  with  carbonic-acid  gas  shows 
the  hour-glass  shape  of  the  organ  ;  lavage  six  to  seven 
hours  after  a  meal  will  occasionally  fail  to  remove  all 
the  contents.  After  the  wash-water  has  come  out 
clear  for  a  time  there  may  occur  a  sudden  admixture 
of  chyme. 

Abnormalities  in  the  Position  of  the  Stomach. 

The  abnormal  positions  of  the  stomach  may  be 
either  congenital  or  acquired.  Among  the  congenital 
abnormalities  we  would  mention  the  transposition  of 
the  stomach  in  the  thoracic  cavity,  which  occurs  if 
there  is  a  partial  or  a  complete  defect  at  the  diaphragm. 
The  stomach  is  found  to  be  situated  on  the  right  side  of 
the  abdomen  (pyloric  portion  to  the  left)  in  cases  of 
general   transposition    of    the   viscera.      Both    these 

'Haller:  "Elem.  Physiol.,"  Lib.  xix.,  Sect.  1,  §3. 


ENTEROPTOSIS,  OR   GLENARD'S  DISEASE.  375 

anomalies  are  extremely  rare.  Among  acquired 
anomalies  a  vertical  position  of  the  stomach  is  occa- 
sionally found.  The  pylorus  is  then  situated  much 
lower  and  farther  to  the  left  than  normally.  This 
condition  is  mostly  found  in  women  and  can  be  easily 
recognized  either  by  the  gastrodiaphane  or  by  inflation 
of  the  stomach,  which  reveals  a  lengthy  but  narrow 
configuration,  its  horizontal  diameter  not  extending 
to  the  right  of  the  linea  alba. 

Descensus  veyitriculi  or  gastroptosis  (low  position  of 
the  stomach)  is  the  most  frequent  anomaly;  it  usually 
occurs  in  connection  with  a  ptosis  of  several  other  in- 
testinal organs,  and  will  therefore  be  best  described 
under  enteroptosis,  or  Glenard's  disease. 

Enteroptosis,  or  Glenard^s  Disease. 

Definition. — Downward  displacement  of  the  stom- 
ach, right  kidney,  and  other  organs  of  the  abdom- 
inal cavity,  attended  with  digestive  disturbances. 

General  Remarks. — Descent  of  the  stomach  as  well 
as  of  other  abdominal  organs  was  described  many 
years  ago  by  Virchow,  Leube,  Landau,  and  other  au- 
thors; yet  to  Glenard  '  must  be  awarded  the  credit  of 
having  first  sufficiently  emphasized  the  importance  of 
this  condition,  of  having  recognized  its  clinical  signifi- 
cance, and  established  it  as  a  distinct  affection. 

The  idea  which  led  the  French  physician  to  the  dis- 
covery of  the  disease  designated  by  his  name  was  the 
fact  that  the  whole  digestive  tract,  which  from  the 
mouth  to  the  anus  is  ten  or  fifteen  times  longer  than 
a  straight  line  connecting  both  points,  is  arranged  in 

I F.  Glenard :  Lyon  Med. ,  1885,  p.  450. 


370  DISEASES   OF   THE   STOMACH. 

the  form  of  different  baldachiDs  suspended  on  six 
loops '  by  means  of  ligaments  at  the  posterior  wall  of 
the  abdomen. 

The  zigzag  direction  of  the  loops  offers  the  possibility 
of  too  great  a  bend,  sometimes  at  such  an  acute  angle 
that  it  causes  obstruction  to  the  passage  of  the  ingesta 
or  secretions  at  the  six  main  points  of  fixation.  This 
might  occur  at  the  gastro-duodenal,  duodeno-jejunal, 
or  transverse/  sigmoid o-rectal  curvatures. 

The  ligaments  are  not  all  of  equal  strength  and  the 
points  of  fixation  of  several  of  them  are  especially 
weak.  This  is  true  of  the  gastro-duodenal  and  the 
transverse  colon  ligaments.  Thus,  from  a  theoretical 
point  of  view,  it  is  apparent  that  the  possibility  exists 
that  the  weak  ligaments  may  give  way  under  favor- 
able conditions,  and  that  a  falling  of  that  part  of  the 
intestine  may  result.  This  would  naturally  exert  in- 
creased traction  on  the  next  fixation  point,  and  might 
cause  an  obstruction  to  the  passage  of  the  contents  of 
the  intestine,  or,  in  other  words,  a  partial  entero- 
stenosis.  In  forty  autopsies  Glenard  several  times 
found  the  colon  transversum  displaced  and  stenosed. 
He  recognized  that  these  changes  in  the  anatomical 
position  must  give  rise  to  troubles,  which  should  be 
considered  dependent  upon  this  condition.  In  examin- 
ing all  his  patients  with  digestive  troubles,  he  found 
that  there  were  many  so-called  "nervous  dyspeptics" 
in  whom  he  could  discover,  by  a  thorough  investiga- 

'  (1)  Anse  gastrique  ;  (2)  anse  duodenale  ;  (3)  anse  ileo-oolique  ; 
(4)  anse  colique  transverse  ;  (4  a)  costo  sous-pylorique  ;  (5  c)  sous- 
pylori -costale  ;  (6)  anse  colo-sigmoidale. 

*  "Colique  sous-costal  droit,"  "colique  sous-costal  gauche,"  "sous- 
pylorique  du  transverse." 


ENTEROPTOSIS,  OR   GLENARD'S   DISEASE.  377 

tion  of  the  abdomen,  that  some  abnormal  position  of 
the  intestines  existed.  He  described  the  following 
objective  points  as  characteristic  of  this  affection : 

1.  Splashing  sound  {clapotement  epigastrique) . 

2.  Pulsation  of  the  abdominal  aorta  {battement 
aortique). 

3.  "Corde  colique  transverse." 

4r.  In  the  right  hypochondriac  region  frequently 
movable  kidney. 

By  the  term  "corde  colique  transverse"  Glenard 
means  the  resistance  which  is  found  lying  over  the 
aorta  3  to  5  cm.  above  the  navel,  running  horizontally 
6  to  10  cm.  on  each  side  of  the  median  line.  This 
gives  the  impression  of  a  ribbon  1  cm.  in  width,  and 
was  supposed  by  Glenard  to  be  the  displaced  colon 
transversum,  for  pressure  on  the  right  iliac  region  at 
the  beginning  of  the  colon  ascendens  produced  rum- 
bling sounds  in  the  "corde  transverse."  He  con- 
sequently concluded  that  all  the  symptoms  in  these 
patients  were  caused  by  this  abnormal  position  of  the 
intestine.     He  named  this  condition  "enteroptosis." 

Etiology. — It  is  generally  accepted  that  the  corset 
plays  a  predominant  part  in  the  causation  of  the 
downward  displacement  of  the  abdominal  organs; 
confinement  is  also  believed  to  be  a  great  factor  of 
this  disorder.  But  besides  these  two  points,  which 
refer  only  to  the  female  sex,  there  are  some  other  con- 
ditions which  likewise  predispose  to  enteroptosis  and 
have  reference  to  both  sexes,  namely,  acute  diseases 
of  a  grave  nature  and  protracted  ailments  accom- 
panied by  a  considerable  loss  of  flesh. 

Enteroptosis  is   found   quite   frequently,  especially 


378  DISEASES   OF   THE   STOMACH. 

among  women.  In  order  to  give  a  clear  illustration 
of  this  fact,  I  take  at  random  the  number  of  patients 
recorded  in  my  jDrivate  day  book  for  the  months  of 
January  and  April,  1896.  In  the  month  of  January 
I  saw  57  male  patients  with  gastric  disturbances; 
among  them  were  4  with  a  distinct  enteroptosis  and 
right  movable  kidney  (third  and  fourth  degrees) ; 
the  number  of  women  with  the  same  disturbances 
amounted  to  33,  and  13  had  distinct  enteroptosis  with 
right  movable  kidney.  The  month  of  April  showed 
similar  figures:  Number  of  male  patients,  84;  enter- 
optosis with  movable  kidney,  5.  Number  of  females, 
69;  enteroptosis  with  movable  kidney,  19.  The  fig- 
ures of  these  two  months  put  together  show: 
Number  of  male  patients,  141 ;  enteroptosis  with 
movable  kidney,  9.  Number  of  female  jjatients,  92 1 
enterojDtosis  with  movable  kidney,  32.  We  find  the 
percentage  of  enteroptosis  to  be  6.2  among  the  male 
patients  with  digestive  disorders,  while  in  the  females 
similarly  afflicted  we  find  the  percentage  to  be  34.8. 
The  great  frequency  of  enteroptosis  which  has  been 
noted  by  Glenard  is  fully  sustained  by  the  figures 
just  given. 

Glenard,  however,  goes  too  far,  when  he  ascribes  all 
digestive  disturbances  to  this  faulty  position  of  the 
abdominal  viscera ;  nor  is  enteroptosis  always  the  only 
cause  of  all  the  morbid  symptoms.  According  to  my 
own  experience,  pronounced  enteroptosis  may  exist 
without  any  manifestations  of  morbid  phenomena.  It 
is  also  self-evident  that  all  kinds  of  .gastric  affections 
occur  in  enteroptosis  as  well  as  in  other  disorders;  for 
enteroptosis  does  not  produce  immunity  from  digee- 


ENTEROPTOSIS,  OR  GLENARD'S   DISEASE.  379 

tive  diseases.  Id  this  way  it  appears  that  the  diagnosis 
of  enteroptosis  will  often  have  to  be  supplemented  by 
the  elucidation  of  some  other  factors  besides  the 
position  of  the  abdominal  viscera.  I,  however,  con- 
cur with  Glenard  that  in  many  instances  enteroptosis, 
as  such,  is  liable  to  produce  symptoms,  and  that  these 
symptoms  can  be  materially  improved  by  the  out- 
lined treatment  of  Glenard  which  will  be  described 
later. 

Symptomatology. — The  first  stage  of  the  disease 
consists  in  a  prolapse  of  the  intestines,  particularly  of 
the  right  part  of  the  colon  transversum,  due  to  a  re- 
laxation of  the  weak  ligamentum  colico-hepaticum. 
The  colon  ascendens  and  colon  transversum,  losing 
their  ligamentous  suspension,  sink  down,  and  thus  the 
colon  transversum,  instead  of  running  straight  across 
the  abdominal  cavity,  runs  obliquely  from  below  up- 
ward. At  the  left  end  the  transverse  colon  is  held  in 
place  by  the  strong  ligamentum  gastro-colicum.  The 
acute  angle  produced  at  this  point  by  the  prolapse  of 
the  other  end  of  the  transverse  colon  causes  a  partial 
occlusion  of  the  lumen  of  the  gut  (enterostenosis). 
The  transverse  colon,  therefore,  remains  contracted 
and  empty,  and  gives  the  condition  described  as  "corde 
transverse. "  Coincident  with  the  descent  of  the  trans- 
verse colon  there  is  a  relaxation  of  the  ligaments 
(mesenteries)  of  the  small  intestines,  and  this  produces 
a  dragging  down  of  the  stomach,  and  causes  the  liver 
and  kidney,  through  the  ligamentum  gastro-colicum, 
to  assume  a  lower  position  than  normal  (Jiepatoptosis 
and  nephroptosis).  Thus  there  may  be  a  prolapse  of 
all  the  intestines — splanchnoptosis.     The  enteroptosis 


380  DISEASES   OF   THE   STOMACH. 

causes  enterostenosis  and  increases  the  specific  gravity 
of  the  intestines,  because  they  do  not  contain  gas,  thus 
diminishing  the  abdominal  tension.  A  circulus  viti- 
osus  is  produced  which,  if  not  interfered  with,  grows 
worse. 

The  subjective  symptoms  of  this  disease  are:  weak- 
ness and  a  constant  feeling  of  lassitude ;  difficulty  in 
digestion  of  fats,  farinaceous  food,  acids,  jDure  wine, 
pure  milk,  with  an  increase  in  the  digestive  troubles 
about  three  hours  after  meals ;  sleeplessness ;  usually 
constipation  or  irregularity  of  the  bowels. 

The  objective  conditions  are :  decreased  tension  of 
the  abdomen ;  prolapsus  of  the  abdominal  contents 
(enteroptosis,  gastroptosis,  frequently  movable  kidney, 
movable  liver) ;  enterostenosis, 

Glenard  distinguishes  three  different  periods  of  the 
disease:  (1)  Atonie  gastrique  par  enteroptose;  (2) 
mesogastrique,  gastroptose;  (3)  neurasthenique,  en- 
terostenose — and  describes  them  as  follows : 

During  the  first  period  of  the  disease  (atonie  gas- 
trique par  enteroptose)  the  patient  eats  everything, 
but  experiences  slight  somnolence  or  a  burning  sensa- 
tion after  meals;  about  2  o'clock  a.m.  the  sleep  is  in- 
terrupted for  a  few  minutes.  Generally  there  is  one 
evacuation  of  the  bowels  in  the  morning,  of  some- 
what diarrhoeic  nature;  there  is  a  gradual  loss  of 
strength. 

In  the  second  period  (mesogastrique,  gastroptose) 
the  patient  avoids  fat,  farinaceous  food,  acids,  milk, 
wine;  complains  of  a  sensation  of  dragging,  false 
hunger,  and  emptiness  about  three  hours  after  meals. 
About  2  o'clock  a.m.   he  remains  awake  for  two  or 


ENTEROPTOSIS,  OR   GLENARD'S   DISEASE.  381 

three  hours;  suffers  from  constipation,  interrupted 
once  in  a  while  by  diarrhoeic  evacuations ;  always  feels 
tired,  particularly  when  arising  and  about  3  o'clock  in 
the  afternoon. 

In  the  third  period  (neurasthenique,  enterostenose) 
the  patient  has  lost  about  thirty  or  forty  pounds  and 
is  not  sufficiently  nourished  ;  he  has  lived  on  milk  diet, 
on  purees,  beef  tea — on  the  most  improbable  meals; 
complains  of  a  weighty  sensation  or  cramps  in  the 
stomach,  and  is  almost  constantly  suffering.  He  does 
not  sleep;  the  constipation  is  most  obstinate;  the 
daily  enemata  with  difficulty  effect  an  evacuation  of 
fatty  scybala  surrounded  by  mucus  or  pseudo-mem- 
branes from  time  to  time.  There  is  constant  com- 
plaint of  great  weakness,  so  that  he  hardly  leaves  the 
room,  and  lies  on  the  lounge  constantly.  He  pre- 
sents the  most  varied  nervous  symptoms:  cerebral, 
spinal,  sympathetic,  both  psychical  and  physical. 

Diagnosis. — As  has  been  shown  by  Ewald,'  the  best 
test  for  the  recognition  of  enteroptosis  is  the  demon- 
stration of  an  existing  gastroptosis.  This  can  occasion- 
ally be  elucidated  by  the  splashing  sound,  which  in 
these  cases  can  be  produced  on  the  left  side  of  the  ab- 
domen over  an  area  extending  from  the  navel  or  some- 
what above  it  down  to  the  symphysis.  The  inflation 
of  air  is  another  means  for  detecting  the  position  of  the 
stomach.  When  the  stomach  is  inflated  the  lesser  cur- 
vature, in  cases  of  gastroptosis,  is  visible  midway  be- 
tween the  ensiform  process  and  the  navel  or  just  in 
the  neighborhood  of  the  umbilicus.  This  is  the  meth- 
od which  Ewald  used  in  his  cases.     Gastrodiaphany 

1 C.  A.  Ewald :  Berliner  klin.  Wochenschr. ,  1890,  Nos.  12  and  13. 


382  DISEASES   OF   THE   STOMACH. 

has  been  recommended  by  me  '  as  a  reliable  means  of 
recognizing  gastroptosis,  and  from  my  further  experi- 
ences in  this  line  I  must  say  that  the  picture  which 
the  gastrodiaphane  produces  in  this  condition  is  very 
striking:  the  stomach  is  here  visible  on  the  abdomen 
as  a  red  zone  lying  between  the  navel  and  the  sym- 
physis. 

Movable  kidney  is  another  essential  symptom  of 
enteroptosis.  The  recognition  of  the  movable  kidney 
is  quite  easy.  It  is  only  necessary  to  practise  palpa- 
tion with  both  hands,  putting  one  hand  on  the  back  of 
patient  behind  the  lumbar  region,  while  the  other 
hand  is  held  flat  below  the  margin  of  the  false  ribs 
covering  the  lower  outside  angle  of  the  abdomen.  By 
having  the  patient  inspire  deeply,  the  kidney,  if  mov- 
able, is  felt  to  slip  between  both  hands ;  slight  pressure 
with  the  hand  on  the  lumbar  region  will  facilitate 
the  recognition  of  an  existing  movable  kidney. 

While  Israel  is  of  the  opinion  that  on  deep  inspira- 
tion even  a  normal  kidney  may  be  partly  felt  by  this 
method  of  examination,  Glenard  considers  all  cases  in 
which  the  kidney  can  be  perceived  by  palpation  as 
abnormal.  This  writer  distinguishes  four  degrees  of 
movable  kidney : 

First  degree  of  nejyhroptosis :  The  lower  part  of 
the  kidney  can  be  palpated  during  deep  inspiration; 
during  expiration  the  kidney  slips  back  to  its  place 
and  it  is  impossible  to  arrest  it. 

Second  degree  :     The  greater  part  of  the  kidney  can 

'  Max  Einhom  :  "  On  Gastrodiaphany. "  New  York  Medical  Jour 
nal,  December  3d,  1892.  " Glenard 's  Disease."  The  Post- Graduate. 
1893,  No.  2. 


ENTEEOPTOSIS,  OR   GLENARD's   DISEASE.  383 

be  palpated  and  it  can  also  be  arrested,  but  its  su- 
perior margin  cannot  be  felt. 

Third  degree :  The  superior  margin  of  the  kidney 
can  be  reached  on  deep  inspiration. 

Fourth  degree :  The  whole  kidney  is  accessible  to 
palpation  even  during  expiration  (the  movable  or 
wandering  kidney  of  the  older  writers). 

Treatment. — As  this  whole  series  of  symptoms  is 
caused  and  explained  by  (1)  enteroptosis,  (2)  entero- 
stenosis,  and  (3)  deficient  nutrition,  the  fundamental 
indications  for  the  successful  treatment  are  pointed 
out  by  Glenard  as  follows : 

1.  The  intestines  must  be  raised  and  maintained  in 
their  position ; 

2.  The  abdominal  tension  must  be  increased ; 

3.  The  bowels  must  be  regulated  ; 

4.  The  secretions  of  the  digestive  tract  and  of  the 
annexed  glands  must  be  stimulated  ; 

5.  The  alimentation  must  be  regulated  and  the 
digestion  assisted ; 

6.  The  organism  must  be  stimulated. 

The  first  two  points  are  accomplished  by  wearing 
a  bandage  reaching  from  the  symphysis  to  the  navel 
and  exerting  a  pressure  upon  the  hypogastrium  from 
below  upward.  This  bandage  raises  the  intestines 
and  increases  the  tension  of  the  abdomen. 

In  order  to  regulate  the  bowels  Glenard  gives  his 
patients,  a  quarter  of  an  hour  before  breakfast,  sodium 
sulphate  4.0,  magnesium  sulphate  3.0,  in  half  a  glass- 
ful of  water;  or  half  a  glass  of  Hunyadi  Janos;  or 
one-quarter  of  a  glass  of  Eubinat ;  or  a  teaspoonful  of 
Carlsbad  salt;  or  pills  consisting  of  0.05  aloes,  or  0.05 


384  DISEASES   OP  THE   STOMACH. 

extractum  rhei.  The  fourth  requirement  must  be  ac- 
comphshed  by  massage,  electricity,  and  lavage  of  the 
stomach ;  and  the  sixth  by  gymnastic  exercises. 

As  to  alimentation  Glenard  has  given  the  following 
table : 

During  the  First  Stage  of  the  Disease. — Boiled 
meat,  roast  game,  odorless  squabs,  brain ;  farinaceous 
vegetables  (lentils,  potatoes),  rice,  carrots;  grapes, 
very  ripe  fruit;  fried  eggs,  oysters,  liver  (fat);  Gerx 
and  Gruyere  cheese;  red  wine  diluted  with  water; 
sauces,  juices,  lards,  fries,  Italian  pat^s,  salad;  pure 
red  wine,  creams,  undiluted  boiled  milk,  fresh 
milk. 

Second  Stage  of  the  Disease. — Eoast  meat  (beef, 
mutton,  veal,  chicken),  lean  ham;  fish  (sole,  white 
fish,  trout);  scrambled  eggs;  fresh  vegetables,  well- 
cooked,  English  style ;  cheeses  (Brie,  Camembert) ; 
baked  apples,  preserves,  compotes;  chocolate,  beer, 
cider  (?),  white  wine  (?). 

TJiird  Stage  of  the  Disease. — Raw  meat  (beef, 
mutton),  raw  eggs,  stale  bread,  coffee  with  milk  (one- 
third  milk,  two-thirds  coffee) ;  coffee,  tea,  water, 
water  with  cognac,  champagne;  broiled  meat  (roast 
beef,  mutton,  lamb  chops,  tenderloin  of  beef) ;  eggs, 
bouillon,  preserves. 

I  agree  with  Glenard  in  regard  to  the  bandage 
which  should  support  and  elevate  the  intestines,  but 
the  medicinal  and  dietetic  treatment  must  be  made 
dependent  upon  the  result  of  a  chemical  analysis  of 
the  stomach  contents;  for,  according  to  my  experi- 
ence, the  chemical  condition  of  the  stomach  in  these 
cases  of  "  enteroptosis"  is  not  always  alike.     In  those 


ENTEROPTOSIS,  OR   GLENARD's   DISEASE.  385 

cases  where  there  is  hyperacidity — which  is  the  case 
with  the  greater  number  of  this  class  of  patients — 
GMnard's  rules  are  excellent;  but  where  there  is  an 
insufficiency  or  an  absence  of  HCl,  the  treatment  will 
have  to  be  modified  accordingly. 


CHAPTER  XIII. 
NERVOUS  AFFECTIONS   OF  THE  STOMACH. 

General  Remarks. 

Deviations  from  the  normal  process  of  gastric  di- 
gestion not  based  upon  pathologico-anatomical  changes 
are  considered  as  gastric  neuroses.  We  are  accus- 
tomed to  ascribe  the  different  functions  of  the  stomach 
to  the  action  of  special  nerves.  Although  physiolog- 
ical experiments  have  not  as  yet  enabled  us  to  discover 
special  nerves  governing  secretion,  motion,  or  sensi- 
bility of  the  organ,  still  clinically  many  facts  speak  in 
favor  of  such  an  assumption.  The  neuroses  of  the 
stomach  are  also  occasionally  designated  as  "func- 
tional disturbances."  The  different  gastric  neuroses 
may  appear  either  separately  or,  occasionally,  in  com- 
bination with  each  other.  As  a  rule,  these  neuroses 
occur  most  frequently  in  women,  especially  between 
the  ages  of  seventeen  and  forty;  in  men  also  the 
middle  period  of  life  shows  a  predilection  for  these 
disturbances.  As  a  predisposing  factor  for  these 
neuroses  the  following  conditions  must  be  recognized : 
severe  mental  exertions,  worry,  unusual  excitement, 
sexual  excesses.  The  recognition  of  the  neurosis  is 
not  always  very  easy.  The  principal  point  of  impor- 
tance is  the  exclusion  of  any  organic  lesion  of  the 
organ.  The  following  symptoms,  which  frequently 
recur  in  gastric  neuroses,  have  been  especially  well 


NERVOUS   AFFECTIONS.  387 

described  by  Boas,'  and  will  facilitate  the  recognition 
of  the  nervous  element  of  the  affections  in  question. 

1,  The  entire  nervous  system  shows  more  or  less 
deviation  from  the  normal.  There  may  be  present 
headache,  insomnia,  conditions  of  depression,  or,  on 
the  other  hand,  excitation,  increased  sensitiveness. 
Objectively  there  may  be  an  increase  or  diminution  of 
the  reflexes  of  the  skin  and  tendons,  hypersesthesia  at 
some,  parassthesia  or  angesthesia  at  other  places.  Fre- 
quently there  exists  constant  or  intermittent  polyuria. 
The  general  condition  may  be  good  or  various  degrees 
of  emaciation  may  be  present. 

2.  The  digestive  system  is  characterized  by  a  con- 
dition of  "labile  gastric  intestinal  function."  The 
subjective  symptoms  are  not  always  necessarily  con- 
nected with  the  act  of  digestion.  The  digestive  com- 
plaints are  usually  independent  of  the  quality  and 
quantity  of  the  ingested  food.  Dietetic  errors  are,  as 
a  rule,  not  followed  by  any  aggravation  of  symptoms; 
while  the  character  of  food  does  not  have  any  influ- 
ence upon  the  severity  of  the  symptoms,  there  are 
occasionally  some  other  factors  in  the  way  of  climate 
and  surroundings  which  play  an  important  part  in 
the  amelioration  or  deterioration  of  the  condition. 
Objectively  changes  in  the  condition  of  gastric  secre- 
tion and  of  the  motor  function  of  the  stomach  as  well 
as  of  the  intestines  frequently  occur.  Thus  complete 
anacidity  may  alternate  during  a  short  period  with 
normal  secretion.  The  condition  of  the  motor  func- 
tions of  the  stomach  frequently  changes.     The  state 

'Boas:  "Specielle  Diagnostik  und  Therapie  der  Magenkrank- 
lieiten,"  2te  Auflage,  p.  204. 


388  DISEASES   OF   THE   STOMACH. 

of  the  bowels  is  also  very  variable ;  thus  constipation 
frequently  alternates  with  diarrhoea,  or,  at  a  time 
when  the  bowels  are  regular,  an  acute  diarrhoea  may 
suddenly  appear. 

According  to  Eosenthal,'  the  neuroses  of  the  stom- 
ach are  best  divided  into:  (1)  Sensory,  (2)  motor,  and 
(3)  secretory  neuroses  of  the  stomach. 

Sensory  Gastric  Neuroses. 

For  the  sake  of  greater  clearness  sensory  gastric 
neuroses  are  best  divided  into  two  main  groups :  (a) 
Comprising  abnormal  sensations  of  a  more  or  less  gen- 
eral character;  (6)  special  sensations  emanating  from 
the  stomach  itself, 
(a)  Abnormal  Sensations  of  a    General    Character. 

The  need  for  food  makes  itself  felt  through  the  sen- 
sation of  hunger,  the  need  for  drink  through  that  of 
thirst.  The  nervous  centre  for  these  sensations  ap- 
pears to  be  located  in  the  medulla  oblongata  (R. 
Ewald '  and  Rosenthal).  The  stomach  is  the  organ 
into  which  all  substances  satisfying  hunger  and  thirst 
are  introduced.  The  act  of  satisfying  the  sensation  of 
hunger  with  relish  is  called  "appetite."  Normally 
there  appears  in  man  a  slight  feeling  of  hunger  at  the 
usual  mealtime.  A  man  relishes  the  food  he  takes 
until  at  the  end  of  the  meal  a  feeling  of  satiety  ap- 
pears. The  latter  may  be  best  characterized  by  noting 
the  point  at  which   the   sensation  of  hunger  has  en- 

'  M.  Rosenthal :  "  Magenneurosen  und  Magenkatarrh,"  Wien  und 
Leipzig,  1886. 

'  R.  Ewald  :  Cited  from  C.  A.  Ewald,  I.  c. ,  p.  380. 


SENSORY   GASTRIC   NEUROSES.  389 

tirely  disappeared.  On  going  beyond  this  point  to 
any  extent — i.e.,  by  continuing  to  introduce  further 
food  into  the  organ — a  sensation  of  weight  and  tight- 
ness around  the  stomach  develops.  This  can  then  be 
hardly  considered  as  a  normal  process,  and  is  the  way 
the  stomach  responds  to  interference  with  its  habitual 
mode  of  work. 

The  time  at  which  hunger  appears  is  physiologically 
variable  and  depends  upon  the  time  persons  are  accus- 
tomed to  take  their  meals.  On  this  account  there  are 
people  who  feel  hungry  only  twice  a  day,  as  they  are 
in  the  habit  of  taking  only  two  meals  daily ;  others 
again  who  feel  hungry  about  every  three  hours,  as 
they  are  accustomed  to  take  five  meals  a  day,  and  so 
on.  Although  the  ingestion  of  food  may  sometimes 
lead  to  some  variations  in  the  time  at  which  hunger 
is  experienced — so  that  a  man  who  is  in  the  habit  of 
taking  a  light  meal  at  a  certain  period  during  the  day, 
after  having  partaken  of  a  much  heavier  meal  than 
customary,  will  perhaps  not  feel  hungry  at  his  next 
meal — this  is  of  less  consequence  than  the  influence  of 
the  time  at  which  the  meals  are  ordinarily  taken. 
Thus  every  one  knows  that  if  he  has  been  accustomed 
to  take  his  lunch,  for  instance,  at  one  o'clock,  the 
hungry  feeling  will  appear  at  one,  and  if  not  satisfied 
within  a  certain  period  of  time  (half  an  hour  to  an 
hour),  then  very  frequently  it  will  disappear  to  return 
at  the  next  mealtime. 

Pathologically  we  find  that  the  above-named  sensa- 
tions may  exist  either  in  an  exaggerated  form,  or  may 
be  greatly  diminished  or  even  absent. 


390  DISEASES   OF   THE   STOMACH. 


Bulimia. 


Bulimia  (/3"y^',  ox,  hiw^,  hunger)  or  cynorexia  (y.'jojv^ 
dog,  o>£|{9,  appetite),  or  hyperorexia,  denotes  a  condi- 
tion in  which  the  feeling  of  hunger  is  enhanced,  ap- 
pearing more  frequently  and  in  a  more  intense  degree 
than  in  the  normal  state.  Bulimia  may  exist  alone 
as  a  primary  affection  or  may  be  associated  with 
various  other  disorders,  and  is  then  considered  as  a 
secondary  affection.  Thus  ulcer  of  the  stomach,  hy- 
perchlorhydria,  cancer  of  the  stomach,  intestinal 
troubles,  tapeworm,  Graves'  disease,  hysteria  and 
neurasthenia,  and  tumors  of  the  brain  are  all  liable  to 
be  complicated  with  bulimia. 

Symptomatologij. — Bulimia  may  appear  periodi- 
cally and  last  only  a  short  time  (a  few  days)  or  may 
exist  chronically  and  last  for  months  or  even  years. 
The  periodical  form  is  usually  characterized  by  much 
greater  intensity  than  the  chronic.  An  attack  of 
bulimia  may  be  described  as  follows :  In  the  midst  of 
perfect  euphoria,  a  feeling  of  intense  hunger  over- 
comes the  patient  with  a  persistent  desire  to  satisfy  it. 
This  hungry  sensation  is  associated  with  a  gnawing 
feeling  in  the  stomach,  and  the  utmost  fear  and 
anxiety,  as  if  something  alarming  were  going  to 
happen.  If  the  feeling  of  hunger  is  not  satisfied  very 
quickly,  then  severe  headache  and  trembling  of  the 
body  or  even  fainting  spells  may  occur.  The  patient 
in  such  a  condition,  as  a  rule,  disregards  convention- 
alities and  tries  to  obtain  whatever  food  he  can,  in 
order  to  overcome  this  painful  craving  of  his  stomach. 
Generally  a  small  quantity  of  nourishment  is  sufficient 


BULIMIA.  391 

to  arrest  the  attack,  sometimes,  however,  large  quan- 
tities of  food  have  to  be  taken.  Thus  Peyer  '  describes 
the  case  of  a  woman  who  was  suddenly  seized  with  an 
attack  of  bulimia,  so  that  she  could  not  return  home 
from  the  house  of  a  neighbor  whom  she  was  visiting. 
In  forty -five  minutes  she  ravenously  devoured  three 
pints  of  milk,  twenty-three  eggs,  and  two  pints  of 
strong  wine.  After  this  meal  she  became  quieter, 
went  to  sleep,  and  awoke  perfectly  well  on  the  next 
day. 

The  primary  cause  of  bulimia  appears  to  be  a  de- 
rangement of  the  nervous  apparatus  for  the  hunger 
sensation.  This  derangement  may  be  either  central  or 
peripheral.  Hypermotility  was  found  by  Leo '  in  a 
patient  troubled  with  bulimia;  but  although  present  in 
some  instances  it  is  by  no  means  a  constant  symptom. 
Thus  Ewald '  reports  a  case  of  bulimia  in  which  the 
motor  function  of  the  stomach  was  perfectly  normal. 

Treatment. — The  treatment  should  always  be 
directed  against  the  primary  cause  of  the  trouble. 
Thus  helminthiasis  must  be  removed  by  extract  of 
male  fern.  Hyperchlorhydria  should  be  treated  by 
carbonate  of  soda,  diabetes  by  a  meat  diet,  and  so  on. 
Cases  of  neurasthenia  or  hysteria  will  have  to  be 
treated  as  such.  The  following  means  at  our  com- 
mand may  be  directed  against  bulimia  as  a  distinct 
disorder : 

Very  frequent  light  meals  (every  two  hours). 

^  A.  Peyer  :  "  Beitrag  zur  Kenntniss  der  Neurosen  des  Magens  und 
des  Darms."     Correspondenzbl.  schweizer  Aerzte,  1888,  No.  20. 

"  Leo  :  "  Verhandlungen  des  Vereins  flir  innere  Medicin, "  Berlin, 
1889. 

3C.  A.  Ewald:  I.  c,  p.  379. 


392  DISEASES   OF   THE  STOMACH. 

The  bromides  should  be  given  in  large  doses,  twice 
daily,  as  for  instance  potassium  or  sodium  bromide,  in 
doses  of  1.5  gm.  (gr.  xx.),  or  bromide  of  strontium  12 
gm.  to  60  c.c.  peppermint  water,  one  teaspoonful  twice 
daily,  or — 

IJ  Amnion,  brom., 

Sodii  brom., aa    8.0     3  ij. 

Aq.  menth.  pip., 60.0     3  ij. 

S.  One  teaspoonful  twice  daily. 

Eosenthal '  recommends  the  use  of  cocaine  in  doses 
of  3  to  5  cgm.  twice  daily. 

Opium  or  codeine,  in  doses  of  3  to  4  cgm.  (gr.  ss.) 
three  times  daily,  may  be  advantageously  employed. 

Arsenic,  is  also  of  value. 

I^  Sol.  arsen.  Fowleri, 

Aq.  menth.  pip., aa  5.0     3  iss. 

S.  Six  drops  three  times  daily. 

A  change  of  climate,  sojourn  in  the  mountains  or  at 
the  seashore,  is  frequently  beneficial. 

Parorexia  {Perversion  of  Appetite). 

The  appetite  is  sometimes  manifested  for  special  and 
peculiar  kinds  of  food,  and  to  this  condition  the  name 
parorexia  has  been  applied.  There  exist  three  degrees 
of  parorexia:  1.  Malacia :  an  increased  desire  for 
spiced  food-stuffs,  as  for  instance  mustard,  salad, 
vinegar,  green  fruits,  etc.  2.  Pica :  the  appetite 
manifests  itself  for  substances  which  are  not  in  reality 
foods,  thus  for  coal,  ashes,  chalk,  earth,  sand,  insects. 
3.  Allotriophagia :  there  seems  to  be  a  craving  for 
substances  which  are  decidedly  disgusting  and  harm- 
ful, as  for  instance  faecal  matter,  needles,  pins,  etc. 

'Rosenthal  :  /.  c. 


AKORIA.  393 

While  the  first  form  (malacia)  is  met  with  in  many 
disturbances  of  the  stomach  or  in  different  neurotic 
conditions  of  the  system  (neurasthenia),  the  latter  two 
conditions  appear  only  in  severe  forms  of  hysteria,  and 
more  frequently  in  idiots  and  lunatics. 

Polyphagia. 

Polyphagia  denotes  a  condition  in  which  excessive 
amounts  of  food  have  to  be  taken  in  order  to  satisfy 
the  feeling  of  hunger.  Polyphagia  is  met  with  in  the 
same  conditions  as  bulimia,  and  especially  in  the  fol- 
lowing disorders:  Cancer  of  the  pancreas  or  spleen, 
fistulous  opening  of  the  gall  bladder,  diabetes,  and 
some  tumors  of  the  brain.  But  polyphagia  may  also 
be  observed  as  a  primary  affection  in  neurotic  persons. 
Like  bulimia,  polyphagia  either  appears  in  the  form  of 
attacks  of  short  duration  or  may  exist  as  a  chronic 
trouble.  The  amount  of  nourishment  which  may  be 
devoured  by  the  patient  during  such  an  attack  of 
polyphagia  is  sometimes  enormous.  Thus  Eosenthal 
reports  the  case  of  a  woman,  twenty-eight  years  old, 
who  devoured  at  one  meal  an  entire  large  fried  goose 
and  a  big  portion  of  bread.  Bouveret'  mentions  a 
case  reported  by  Percy :  The  patient,  Tarare  by  name, 
when  seventeen  years  old  could  partake  of  one  hun- 
dred pounds  of  meat  in  twenty-four  hours. 

Akoria. 

By  akoria  is  designated  the  absence  of  the  sensation 
of  satiety  (xop^wop.c,  I  feel  satiated).  The  main  symp- 
tom of  this  condition  consists  in  the  loss  of  the  feeling 

'L.  Bonveret-.  "Traitedes  Maladies  de  I'Estomac,"  Paris,  1893, 
p.  654. 


304  DISEASES   OP   THE   STOMACH. 

a  person  normally  experiences  at  the  end  of  the  meal 
which  tells  him  that  he  has  had  enough.  The  patient 
with  akoria  never  knows  when  to  stoj)  eating.  Fre- 
quently akoria  is  found  combined  with  polyphagia, 
hut  not  always.  It  is  met  with  in  similar  conditions 
as  bulimia  and  polyphagia,  neurasthenics  and  hysterics 
forming  the  large  majority  of  cases. 

Nervous  Anorexia. 

Under  the  term  anorexia  ('''>£|t?,  appetite)  is  under- 
stood a  complete  absence  of  the  sensation  of  hunger, 
combined  with  loss  of  appetite.  While  anorexia  is 
met  with  in  almost  all  organic  as  well  as  functional 
disorders  of  the  stomach,  "nervous  anorexia"  may  at 
times  appear  as  a  primary  affection,  unassociated  with 
the  conditions  just  mentioned.  The  cause  of  this 
primary  anorexia  may  be  either  a  depressed  condition 
of  the  hunger  centre  or,  according  to  Rosenthal,  a 
kind  of  hypersesthesia  of  the  gastric  mucous  mem- 
brane. As  etiological  factors  are  frequently  found 
great  mental  depression,  as  after  a  death  in  the 
family,  worry,  anxiety,  fright,  etc. 

Symptomatology. — At  first  the  patient  complains  of 
loss  of  appetite  and  begins  to  eat  less.  As  a  rule,  all 
kinds  of  meat  are  first  discarded  from  the  bill  of  fare. 
Later  on  bread,  butter,  and  afterwards  most  solid 
foods  are  avoided  and  the  patient  subsists  only  on  a 
small  quantity  of  milk  and  some  soup.  For  quite  a 
while  the  patients  apparently  maintain  their  healthy 
appearance  and  do  not  even  seem  to  lose  in  weight. 
The  small  quantities  of  food  the  patient  takes  are  now 


NERVOUS   ANOREXIA.  395 

still  further  reduced.  Even  the  encouragement  on 
the  part  of  the  family  to  take  more  nourishment  fails 
to  have  any  effect ;  the  patient,  as  a  rule,  obstinately 
refusing  to  do  so.  It  was  Sollier  '  who  laid  particular 
stress  upon  this  symptom,  and  suggested  designating 
this  condition  by  the  name  of  ^''  sitieirgy'''  {tIto-,  food, 
and  el'pyoj,  refuse).  At  this  stage  the  patients  lose 
considerably  in  weight  and  begin  to  look  emaciated, 
have  cold  extremities,  a  slow  pulse  (50  to  60)  and  re- 
duced temperature  (95  to  96°  F.);  they  grow  anaemic 
and  weak,  and  very  soon  are  hardly  able  to  leave  their 
beds.  The  appearance  of  such  a  patient  in  this  stage 
of  the  disease  is  very  similar  to  that  of  a  consumptive. 
The  face  is  pale,  the  eyes  sunken,  the  skin  dry,  the 
extremities  slightly  cyanosed,  and  the  abdomen  re- 
tracted. If  the  patient  still  continues  to  refuse  food, 
the  condition  may  terminate  fatally.  Such  cases  of 
nervous  anorexia  ending  in  death  have  been  reported 
by  Gull,°  Charcot,"  Eosenthal,"  and  others. 

Eosenthal's  case  was  as  follows:  The  patient, 
female,  seventeen  years  old,  had  suffered  for  eighteen 
months  from  anorexia.  After  this  period  she  took 
only  30  to  40  gm.  of  milk  per  day.  The  patient  be- 
came emaciated  and  looked  like  a  skeleton.  She  could 
not  sleep  and  could  not  leave  her  bed.  Isolation  of 
the  patient  or  forced  alimentation  could  not  be  em- 
ployed under  the  existing  circumstances.  Symptoms 
of  rapidly  progressing  inanition  appeared,  in  connec- 
tion with  shortness  of  breath,  dysphagia,  and  alalia, 

'Sollier:  Eevue  de  medecine,  aout,  1891. 
2  Gull .  Lancet,  1868. 

3 Charcot:  " (Euvres  completes, "  t.  ill.,  p.  240. 
*  Rosenthal :  I.  c. 


396  DISEASES   OF   THE   STOMACH. 

all  indicating  anaemia  of  the  bulbar  centres,  the  case 
terminating  fatally. 

Diagnosis. — After  the  development  of  nervous 
symptoms  no  diflBculty  is  encountered  in  making  the 
diagnosis  of  anorexia.  It  is  necessary  first  of  all  to 
exclude  organic  affections  of  the  stomach.  The  early 
stage  of  tuberculosis  may  at  times  be  mistaken  for 
nervous  anorexia,  especially  if  there  exists  no  cough 
or  if  tubercle  bacilli  are  absent  in  the  sputum.  One 
point,  which  is  quite  valuable  in  making  the  diagnosis 
of  nervous  anorexia,  is  the  circumstance  that  patients 
with  the  latter  condition  are  not  in  any  way  alarmed 
about  their  loss  of  appetite,  while  anorexia  existing  in 
organic  disorders  of  the  stomach,  like  cancer,  etc., 
evokes  fear  and  anxiety. 

Treatment. — In  the  early  stage  of  the  disease  the 
treatment  is  quite  easy.  It  is  merely  necessary  to 
impress  the  patient  with  the  idea  that  he  must  take 
sufficient  food.  The  meals  should  be  taken  at  regu- 
lated periods.  The  patient  should  be  given  food  with- 
out any  previous  questioning  as  to  whether  he  would 
like  it  or  not.  At  meal-times  he  should  be  encouraged 
to  take  his  entire  portion.  A  liberal  variety  of  foods 
is  also  of  importance.  In  the  way  of  medicines  most 
of  the  bitter  tonics,  which  stimulate  the  appetite,  are 
indicated.  Thus  nux  vomica,  in  the  form  of  the 
tincture,  may  be  given  in  doses  of  ten  drops  three  times 
daily,  or  fluid  extract  of  condurango,  twenty  drops 
three  times  daily.  Boas  recommends  fluid  extract  of 
Peruvian  bark,  one  teaspoonful  three  times  daily. 
Orexinum  basicum  in  doses  of  2  to  3  dcgra.,  in  wafers 
three  times  daily,  is  also  useful.     All  these  stomachics 


NERVOUS  ANOREXIA.  397 

should  be  given  about  one-quarter  of  an  hour  before 
meals. 

The  longer  the  disease  has  existed  the  more  difficult 
it  becomes  to  combat  it  successfully.  If  it  is  already 
of  long  standing,  and  has  led  to  high  degree  of  ema- 
ciation and  other  pronounced  symptoms  of  inanition, 
then  treatment  at  the  home  of  the  patient  is  hardly 
ever  successful.  Charcot  first  laid  stress  upon  the 
importance  of  isolating  the  patient  from  his  surround- 
ings. This  plan  of  treatment  has  been  still  further 
advanced  by  Weir  Mitchell '  in  this  country,  and  this 
method  is  known  as  the  Weir  Mitchell  rest  cure.  The 
principle  of  this  cure  consists  first  in  isolation  of  the 
patient  from  his  famil}^ ;  secondly,  in  strict  supervision 
by  the  physician,  and  by  a  constant  attendant ;  thirdly, 
in  ample  feeding,  so  that  a  state  of  hypernutrition 
may  be  established  ;  fourthly,  in  the  application  of 
massage  and  electricity,  which  may  be  considered  as 
adjuncts  to  the  above. 

In  cases  in  which  food  is  absolutely  refused,  even 
after  isolation,  forced  alimentation  or  gavage  (feeding 
by  means  of  the  tube)  becomes  necessary.  Frequently 
after  having  nourished  the  patient  by  artificial  means 
for  a  few  days,  he  gains  the  conviction  that  his 
stomach  is  able  to  digest  food  and  then  begins  to  eat 
spontaneously.  Good  fresh  air  and  an  organic  iron 
preparation  like  Gude's  peptomangan  or  Pizzala's  or 
Dietrich's  albuminate  of  iron  or  Boehringer's  ferratin 
may  be  advantageously  administered,  especially  after 
the  patient  has  begun  to  improve.  Arsenic  may  also 
be  administered,  either  alone  or  in  conjunction  with 
1  AVeir  Mitchell :  "Fat  and  Blood, "  Philadelphia,  1884. 


398  DISEASES   OF   THE   STOMACH. 

the  above-mentioned  iron  preparations;  thus  Fowler's 
solution,  two  to  three  drops  three  times  daily  in  water, 
or  Levico  or  Eoncegno  mineral  waters  may  be  given, 
one  to  two  tablespoonfuls  daily.  As  a  rule,  the  patient 
should  not  leave  the  sanitarium  until  he  has  regained 
his  former  weight.  In  the  latter  instance  there  is  no 
danger  of  relapses. 

{b)  Special  Sensations  Within  the  Stomach  Itself. 

In  its  normal  state  the  stomach  barely  transmits 
any  sensations  whatever  to  our  consciousness.  As 
a  rule  we  lose  track  of  the  food  we  take  as  soon  as 
it  has  passed  the  palate  and  has  been  swallowed. 
Plain  articles  of  food  and  the  most  delicious  dishes  are 
equally  quickly  forgotten.  Cold  articles  of  food  and 
warm  beverages  do  not  manifest  their  presence  by  any 
special  sensations  within  the  stomach.  Notwithstand- 
ing these  facts  it  is  certain  that  the  stomach  physio- 
logically is  not  void  of  sensation.  Thus  ice-water 
taken  in  large  quantities  on  an  empty  stomach  gives 
rise  to  a  sensation  of  slight  cold  in  the  gastric  region, 
especially  near  the  scrobiculus.  The  faradic  current 
applied  within  the  stomach  (one  electrode  within  the 
organ,  the  other  at  the  back)  produces  a  sensation 
either  of  slight  burning  or  of  weight  in  the  gastric 
region,  provided  the  current  is  sufficiently  strong.  If 
it  were  not  for  these  experiments,  we  might  imagine 
that  the  stomach  is  an  organ  which  normally  does  not 
transmit  any  perception  to  the  brain.  This  fact, 
which  applies  alike  to  the  stomach  as  well  as  to  the 
other  vegetative  organs  of  our  system,  is  of  great  im- 
portance and  a  wise  provision  of  nature ;  for  it  enables 


GASTRIC   IDIOSYNCRASIES.  399 

"US  to  occupy  ourselves  with  all  kinds  of  brain  work 
without  being  constantly  disturbed  by  the  functional 
processes  and  needs  of  our  digestive  organs. 

In  contrast  to  the  small  degree  of  sensation  which 
physiologically  exists  in  the  stomach,  the  activitj^  of 
the  sensory  apparatus  may  be  pathologically  increased 
and  thus  give  rise  to  marked  discomfort. 

Gastric  Idiosyncrasies. 

We  sometimes  meet  with  persons  who  manifest  an 
idiosyncrasy  toward  certain  substances,  the  ingestion 
of  which  gives  rise  to  symptoms  emanating  from  the 
alimentary  tract  alone  or  combined  with  other  dis- 
orders, especially  of  the  skin.  The  articles  most  apt 
to  cause  these  disturbances  are  certain  kinds  of  fruit, 
especially  strawberries,  lobsters,  soft-shell  crabs,  oys- 
ters, fish ;  but  besides  these  substances  there  are  sev- 
eral other  articles  of  food  which  may  produce  dis- 
agreeable symptoms  in  certain  individuals.  Thus  I 
know  of  several  members  of  one  family  who  betray 
very  unpleasant  symptoms  (feelings  of  pressure,  pain, 
belching)  if  a  trace  of  onion  is  added  in  the  prepara- 
tion of  the  food.  In  all  these  instances  this  is  not  an 
imaginary  trouble,  for  even  if  the  substances  men- 
tioned are  given  in  a  disguised  form,  so  that  the 
person  is  unconscious  of  taking  them,  he  will  never- 
theless suffer  from  the  same  symptoms.  Generally 
only  gastric  symptoms  are  produced:  pressure,  pain, 
belching,  rarely  nausea  and  vomiting;  sometimes  in 
addition  to  these  there  appear  eruptions  on  the  skin, 
either  erythema  or  urticaria.  It  is  remarkable  that 
in  these  instances  the  same  individual  always  mani- 


400  DISEASES   OP  THE   STOMACH. 

fests  the  same  symptoms  upon  taking  the  respective 
article  against  which  he  has  an  idiosyncrasy. 

Talma  *  described  several  cases  in  which  there  was  an 
idiosyncrasy  against  hydrochloric  acid.  The  slightest 
quantities  of  a  highly  diluted  solution  of  hydrochloric 
acid  (1 :  750)  produced  pains  within  the  stomach.  I 
also  have  observed  a  case  in  which  severe  pains  in  the 
gastric  region  usually  appeared  one  to  two  hours  after 
meals  for  a  period  of  over  seven  years.  The  analysis  of 
the  gastric  contents  one  hour  after  the  test  breakfast 
revealed  the  presence  of  free  hydrochloric  acid  and  a  de- 
gree of  acidity  of  40.  As  the  symptoms  corresponded 
to  those  found  in  hyperchlorhydria,  I  administered 
alkalies,  notwithstanding  the  fact  that  the  acidity  in 
this  case  was  rather  diminished.  The  symptoms  dis- 
appeared at  once,  and  the  patient,  who  was  quite  ema- 
ciated, began  to  gain  in  weight  rapidly.  The  treat- 
ment was  continued  for  over  six  months,  and  the 
improvement  persisted.  Here  the  pains  were  probably 
due  to  a  kind  of  idiosyncrasy  of  the  stomach  against 
its  own  hydrochloric  acid. 

In  all  these  cases  nothing  can  be  done  to  rid  the 
stomach  of  this  peculiarity,  and  the  persons  affected 
must  abstain  from  the  offending  articles,  or  else  suffer 
for  their  indulgence. 

Abnormal  Sensations. 

Sensations  of  heat  or  more  seldom  of  cold,  of  heavi- 
ness or  of   a  foreign  body  within   the   stomach   are 
present  in  some  cases;  and  these  may  manifest  them- 
selves no  matter  whether  the  stomach  be  empty  or 
'Talma:   Zeitschr.  f.  klin.  Medicin,  1884,  Bd.  viii.,  p.  407. 


HYPERiESTHESIA   OF   THE   STOMACH.  401 

not.  They  are  not  due  to  changes  in  the  chemical 
condition  of  the  gastric  juice,  but  are  merely  symp- 
toms originating  from  the  nerves  of  the  stomach. 
With  these  sensations  we  may  also  class  the  feeling 
of  constriction  or  of  cramp  within  the  organ  and  the 
"epigastric  heating."  The  latter  is  sometimes  due  to 
an  increased  pulsation  of  the  abdominal  aorta.  While 
in  the  normal  state  people  never  notice  these  pulsa- 
tions, in  those  affected  the  beating  sensation  is  very 
tormenting  and  is  sometimes  the  cause  of  many  sleep- 
less nights.  All  these  abnormal  sensations  are  usually 
found  in  nervous  people,  neurasthenics  or  hj^sterics. 

Nausea  also  belongs  to  the  abnormal  sensations. 
Besides  its  occurrence  in  organic  affections  of  the 
stomach  it  is  also  found  alone,  and  it  is  then  called 
"nervous  nausea."  It  is  met  with  in  diseases  of  the 
central  nervous  system  and  in  both  neurasthenics  and 
hysterics.  Sometimes  it  is  also  caused  by  affections 
in  distant  organs,  as  for  instance  the  uterus  or  the 
ovaries,  and  must  then  be  considered  as  a  reflex  symp- 
tom. Nausea  appears  most  frequently  in  the  fasting 
state,  sometimes,  however,  the  patient  also  experiences 
the  nauseous  feeling  shortly  after  meals,  from  half  an 
hour  to  an  hour.  The  treatment  should  therefore  be 
directed  principally  against  the  general  condition. 
Sometimes  the  intragastric  application  of  the  galvanic 
current  will  greatly  facilitate  the  cure. 

HypercBsthesia  of  the  Stomach. 

In  hypersesthesia  of  the  stomach  there  is  an  ab- 
normal sensitiveness  of  the  mucous  membrane  even 
after  the  ingestion  of  ordinary  food.     The  patient  ex- 

26 


402  DISEASES   OF   THE   STOMACH. 

periences  a  sensation  of  fulness,  of  slight  burning, 
sometimes  even  of  pains  in  the  gastric  region  after 
meals.  Many  organic  affections  of  the  stomach  are 
accompanied  by  this  condition.  As  a  primary  affec- 
tion it  appears  most  frequently,  according  to  Eosen- 
heim,'  in  chlorotic  girls  and  women.  Occasionally  it 
is  met  with  in  people  with  a  weakened  constitution; 
thus  after  excesses  in  baccho  et  in  ve7iere,  or  after  long 
periods  of  unsuitable  dieting. 

Symptomatology. — In  the  mild  form  of  hyperaes- 
thesia  the  patient  experiences  a  sensation  of  weight  or 
fulness  after  meals.  If  the  disease,  however,  is  more 
pronounced,  real  pains  occur  after  meals,  and  the 
stomach  after  a  while  may  become  so  irritable  that 
the  contact  of  food  with  the  mucous  membrane  pro- 
duces vomiting.  In  the  latter  instance  the  food  is 
partly  rejected  soon  after  the  meal.  As  a  rule  only  a 
small  quantity  of  the  ingested  food  is  vomited,  while 
the  greater  part  is  thoroughly  digested.  That  is  the 
reason  why  in  these  instances  the  patient  does  not 
emaciate.  If,  however,  the  bulk  of  the  food  be 
ejected,  this  symptom  may  soon  lead  to  grave  inani- 
tion. The  disagreeable  sensations  which  exist  in  this 
affection  frequently  lead  to  a  diminution  of  the  quan- 
tity of  food  taken  (a  condition  develops  which  may  be 
termed  "sitophobia" — fear  of  food),  and  in  this  way 
again  the  nutrition  may  be  impaired. 

Diagnosis. — In  addition  to  the  above  symptoms  an 
examination  discloses  that  the  gastric  and  epigastric 
regions  are  painful  on  pressure.  The  secretory  and 
motor  functions  of  the  stomach  may  be  found  normal 

'  Th.  Rosenheim:  Berl.  kliu.  Wochenschr.,  1890. 


HYPERiESTHESIA    OF   THE    STOMACH,  403 

or  a  slight  degree  of  hyperchlorhydria  may  exist.  In 
the  differential  diagnosis  we  must  exclude  gastric 
catarrh,  ulcer  and  erosions  of  the  stomach,  before 
diagnosing  hypersesthesia  as  such.  In  catarrh  of  the 
stomach  the  sensation  of  fulness  or  weight  appears,  as 
a  rule,  not  immediately  after  meals,  but  some  time 
afterward.  Besides  there  exist  in  catarrh  of  the 
stomach  many  other  symptoms  (loss  of  appetite,  a 
diminished  secretion,  etc.),  which  are  not  met  with  in 
this  condition.  In  ulcer  of  the  stomach  the  pains  are 
more  violent.  They  are  also  dependent  upon  the 
quality  of  the  food  ingested,  while  in  hypersesthesia 
the  abnormal  sensations  are  pretty  much  the  same 
whether  coarse  substances  or  very  light  food  be  in- 
gested. In  erosions  of  the  stomach  the  pains  are  also 
usually  of  a  light  nature,  but  here,  as  in  ulcer,  we 
find  that  the  pains  depend  to  a  certain  extent  upon  the 
quality  and  quantity  of  the  food  taken.  Another 
point  of  importance  in  this  condition  is  the  results 
obtained  after  the  washing  out  of  the  stomach  in  the 
fasting  condition  of  the  patient.  In  erosions  of  the 
stomach,  as  a  rule,  several  (two  to  four)  small  pieces 
of  gastric  mucosa  are  found  in  the  wash-water;  in 
hypersesthesia  this  does  not  occur. 

Treatment. — For  the  hypersesthesia  occurring  in 
chlorotic  persons  Eosenheim  proposed  the  following 
treatment:  The  patient  should  be  kept  in  bed,  and  the 
Priessnitz  compress  applied  to  the  gastric  region.  The 
diet  should  consist  at  first  of  milk,  to  which  small 
amounts  of  lime  water  are  added,  and  which  should  be 
taken  with  a  spoon.  The  addition  of  small  quantities 
of  tea  or  coffee  to  the  milk  is  permissible.     After  a 


404  DISEASES  OP   THE   STOMACH. 

while  the  yolk  of  an  egg  with  sugar  and  small  quan- 
tities of  cognac,  wine  jelly,  scraped  meat,  or  toasted 
bread  are  given.  Of  medicaments,  Rosenheim  advises 
the  internal  use  of  nitrate  of  silver. 

IJ  Arg.  nitr., 0.3    gr.  iij. 

Aq.  dest 100.0     |  iij. 

S.  Half  a  tablespoonf ul  in  a  wineglassful  of  water,  three  times 
daily,  half  an  hour  before  meals. 

When  the  stomach  has  become  less  irritable,  the 
patient  should  begin  cautiously  with  solid  food  and 
tonics  like  iron  and  arsenic,  in  order  to  restore  the 
organism  to  its  normal  condition. 

In  cases  of  h5"per9esthesia  not  originating  from 
chlorosis  the  best  treatment  consists  in  the  administra- 
tion of  the  bromides  for  a  period  of  one  or  two  months. 

Gastralgia. 

Synonyms. — Cardialgia,  gastrospasmus,  and  gastro- 
dynia. 

By  the  term  gastralgia  is  designated  the  occurrence 
of  attacks  of  pains  of  more  or  less  severity  in  the  gas- 
tric and  epigastric  regions.  These  persist  for  a  certain 
period  and  alternate  with  perfectly  free  intervals. 

Symptomatology. — The  attacks  of  pains  rarely  ap- 
pear suddenly.  As  a  rule,  they  are  preceded  by  short 
periods  of  various  abnormal  sensations ;  thus  a  slight 
feeling  of  nausea  or  of  tension  in  the  gastric  region 
may  exist.  Increased  salivation  is  also  frequently  one 
of  the  prodromal  symptoms.  Headache,  feelings  of 
faintness  or  vertigo  may  also  precede  the  real  attack. 
Very  soon  afterward  an  intense  pain  appears  in  the 
epigastric  region,  extending  especially  to  the  left  side. 


GASTRALGIA.  405 

There  exist  a  crampy  sensation  and  a  feeling  of  con- 
striction, or  there  may  be  a  feeling  of  intense  burning. 
These  pains  and  sensations  frequently  radiate  to  the 
back,  to  the  shoulder  blades,  and  over  the  whole  ab- 
domen. At  such  times  the  patient  is  overcome  by  a 
feeling  of  great  anxiety.  The  extremities  often  grow 
cold,  and  cold  perspiration  appears  on  the  forehead. 
The  face  is  extremely  pale,  and  bears  the  expression 
of  anguish  and  anxiety.  The  patient  frequently  is 
unable  to  lie  straight,  and  often  assumes  a  bent  posi- 
tion, so  that  the  abdominal  muscles  are  not  stretched, 
but  kept  in  a  curved  and  relaxed  condition.  Some- 
times the  patient  puts  a  pillow  upon  his  abdomen  and 
curls  himself  around  it,  holding  it  with  his  arms. 
The  character  of  the  pulse  is  variable.  As  a  rule,  it 
is  accelerated,  sometimes,  however,  it  is  rather  re- 
tarded. The  gastric  region  is  mostly  sunken ;  in  rare 
instances  protruding.  While  this  region  is  sensitive 
to  slight  palpation,  a  more  profound  pressure  does  not, 
as  a  rule,  cause  any  pain,  and  frequently  rather  re- 
lieves the  patient's  suffering  for  a  moment.  The  dur- 
ation of  such  an  attack  is  very  variable ;  it  may  last 
fifteen  minutes  only  or  several  hours.  At  the  end  of 
the  attack  the  pains  disappear  quite  suddenly,  and  the 
patient  now  experiences  a  sensation  of  hunger.  If 
the  attack  was  of  short  duration  (half  an  hour  or  so) 
the  patient  does  not  retain  any  symptoms  of  malaise 
after  it,  and  is  able  to  attend  to  his  usual  work.  It 
is  quite  different  with  a  severe  attack  that  has  lasted 
several  hours.  The  latter  leaves  a  feeling  of  extreme 
weakness  for  several  days,  during  which  the  patient 
has  to  remain  abed. 


406  DISEASES   OF   THE   STOMACH. 

The  frequency  of  these  attacks  is  very  variable,  and 
different  in  each  case.  In  some  cases  the  attacks 
occur  once  in  a  few  months  or  once  in  a  year,  while  in 
others  they  appear  every  week  or  even  every  day. 
The  attacks  of  idiopathic  gastralgia  do  not  seem  to  be 
dependent  upon  the  quality  or  quantity  of  food  in- 
gested, nor  to  show  any  relation  to  the  time  of  its 
ingestion. 

EtioJoyy. — With  regard  to  etiology,  gastralgia  may 
be  divided  into  the  following  forms : 

(1)  Gastralgia  of  stomachic  origin ;  (2)  central  gas- 
tralgia ;  (3)  neurotic  gastralgia ;  (4)  constitutional 
gastralgia ;  (5)  reflex  gastralgia. 

Gastralgia  of  Stomachic  Origin. — Besides  occurring 
in  connection  with  gastric  affection,  as  for  instance 
ulcer,  cancer,  hyperchlorhydria,  peritonitic  adhesions, 
gastralgia  may  exist  as  a  primary  affection  of  the 
stomach,  either  without  any  visible  cause  or  after  the 
ingestion  of  certain  unusual  or  unaccustomed  articles 
of  food  or  spices ;  thus  very  strong  black  coffee  or  ice- 
cream may  provoke  an  attack  in  people  not  accus- 
tomed to  these  substances. 

Gastralgia  of  Central  Origin. — Diseases  of  the 
brain  are  very  seldom  accompanied  by  gastralgia. 
Spinal  disorders  are  much  more  frequently  associated 
with  the  latter  condition.  In  tabes  especially  gastral- 
gia frequently  occurs.  Charcot  deserves  much  credit 
for  having  first  recognized  the  dependence  of  these 
gastric  pains  upon  the  spinal  trouble.  He  described 
these  attacks  under  the  name  of  "crises  gastriques." 
The  pathological  basis  for  tlje  latter  condition  was 
found   to  consist  in  a  sclerotic  degeneration   of   the 


GASTRALGIA.  407 

vagus  Ducleus  or  the  vagus  trunk  (Kahler/  Demange/ 
Landouzy  and  D^jerine,"  Oppenheim ').  The  gastric 
crises  differ  but  little  from  the  usual  gastric  attacks. 
As  a  rule,  they  begin  with  a  prodromal  period  of  lan- 
cinating pains  in  the  limbs  or  in  both  upper  and  lower 
extremities,  and  also  with  excessive  vomiting.  The 
attack  in  many  points  greatly  resembles  that  of  con- 
tinuous periodic  hypersecretion,  and  lasts  just  about 
as  long.  Examination  of  the  stomach  contents  before 
and  during  the  attack  has  not  revealed  anything 
characteristic  (Von  Noorden'  and  Ewald  "). 

Besides  tabes  dorsalis,  other  lesions  of  the  spinal 
cord  which  involve  the  vagus  nucleus  may  also  pro- 
voke gastralgia.  Thus  Leyden'  describes  it  among 
the  symptoms  of  subacute  myelitis,  and  Oser'  in  a  case 
of  pressure  myelitis.  This  type  of  gastralgia  accom- 
panying spinal  troubles  appears  of  special  importance, 
inasmuch  as  it  is  frequently  one  of  the  first  symptoms 
of  the  real  trouble.  The  gastric  crises  may  in  some 
instances  precede  for  several  years  the  other  symptoms 
of  locomotor  ataxia.  It  is  hardly  necessary  to  men- 
tion that  in  all  cases  of  periodic  gastralgia  we  should 
examine  the  condition  of  the  nerves  and  of  the  cord 
(knee  reflex,  Eomberg's  symptom,  sensitiveness  of  the 
skin,  and  reaction  of  the  pupils). 

'Kahler:  Prager  Zeitsch.  f.  Heilknnde,  Bd.  ii. 
^  Demange  :  Eevue  de  medecine,  1882. 
^Landouzy  et  Dejerine  :  Societe  de  biologie,  1884. 
^Oppenheim:  Berl.  klin.  Wochenschr. ,  1885. 
^C.  von  Noorden  :  "Pathologie  der  gastrischen  Krisen."    Charite 
Annalen,  1880. 

« C.  A.  Ewald  -.I.e.,  p.  403. 

^E.  Leyden:  Zeitschr.  f.  klin.  Medicin,  1882,  Bd.  iv.,  p.  605. 

^O^er  :  "Die  Neurosen  des  Magens, "  Wien  und  Leipzig,  1885. 


408  DISEASES   OF   THE   STOMACH. 

Neurotic  Gastralgia. — Gastralgia  often  occurs  as 
one  of  the  symptoms  of  either  hysteria  or  neurasthe- 
nia. Both  conditions  are  characterized  by  the  peculiar 
symptoms  which,  if  jDresent  in  a  sufficient  number, 
will  make  the  diagnosis  easy.  Sometimes,  however, 
the  gastralgia  may  exist  for  a  long  time  as  the  only 
symptom  of  either  neurasthenia  or  hysteria.  It  is 
then  more  difficult  to  recognize  the  real  nature  of  the 
trouble. 

Constitutional  Gastralgia. — Constitutional  gas- 
tralgia is  caused  by  some  abnormal  condition  of  the 
blood,  due  either  to  infection,  intoxication,  or  malnu- 
trition. Among  the  infections,  malaria  is  frequently 
the  cause  of  intense  gastralgia.  The  gastralgia 
may  be  associated  with  other  symptoms  of  this  dis- 
ease, chills,  fever,  etc.,  or  it  may  appear  alone.  It 
is  characteristic  of  gastralgia  of  malarial  origin  to  ap- 
pear either  every  day,  or  every  other  day,  or  every 
third  day  at  the  same  hour.  I  have  frequently 
seen  this  form  of  gastralgia  accompanied  by  intense 
vomiting  and  by  a  condition  of  hyperaesthesia  of 
the  stomach  prevailing  in  the  intervals  between  the 
attacks. 

The  intoxications  causing  gastralgia  are  very  nu- 
merous. Thus  chronic  lead  poisoning,  an  extensive 
use  of  the  mercurial  preparations,  the  excessive  use  of 
tobacco,  frequently  evoke  typical  attacks.  Gout  is 
also  sometimes  found  to  give  rise  to  gastric  attacks. 
Malnutrition,  which  is  always  associated  with  anaemia, 
is  frequently  found  complicated  with  gastralgia,  es- 
pecially in  young  persons  (chlorosis).  In  these  cases 
it  is,  as  a  rule,  very  difficult  to  decide  whether  the 


GASTKALGIA.  409 

gastralgia  is  due  to  the  ansemia  or  to  a  real  organic 
trouble  of  the  stomach,  namely,  ulcer. 

Reflex  Gastralgia. — This  group  occurs  more  fre- 
quently in  women.  Eeflex  gastralgia  may  be  caused 
by  abnormal  conditions  in  distant  organs,  such  as  the 
uterus,  ovaries,  or  tubes.  In  men  also  diseases  of  the 
genito-urinary  organs  give  rise  to  similar  troubles. 
Another  frequent  cause  of  reflex  gastralgia  is  an  ab- 
normal position  of  the  abdominal  organs.  Thus  en- 
teroptosis,  gastroptosis,  nephroptosis,  hepatoptosis  are 
all  occasionally  the  cause  of  gastric  pains.  Hydrone- 
phrosis has  also  been  stated  by  Eenvers'  to  be  the 
cause  of  gastralgia,  and  I  myself  have  observed  one 
•case  of  this  kind. 

Diagnosis. — To  establish  the  diagnosis  of  gastralgia 
it  is  of  importance  to  exclude  (1)  all  organic  and  func- 
tional diseases  of  the  stomach  accompanied  by  pain, 
and  (2)  conditions  likewise  provoking  pains  in  the 
gastric  region  which,  however,  are  not  due  to  the 
stomach. 

Among  the  organic  affections  of  the  stomach  which 
give  rise  to  gastralgia,  and  may  occasionally  be  con- 
founded with  idiopathic  gastralgia,  are :  (a)  Chronic 
gastric  catarrh ;  (6)  cancer  of  the  stomach ;  (c)  ulcer 
of  the  stomach ;  {d)  stenosis  of  the  pylorus. 

In  chronic  gastric  catarrh  the  pains  are  very  seldom 
intense,  they  have  a  more  continuous  character,  and 
do  not  appear  in  paroxysms. 

In  cancer  of  the  stomach  the  pains  may  be  intense 
at  times,  but  they  are  also,  as  a  rule,  more  steady, 
never  leaving  any  perfectly  free  intervals,  while  in 

iRenvers:  Berl.  klin.  Wochenschr.,  1888,  No.  53. 


410  DISEASES   OP   THE   STOMACH. 

idiopathic  gastralgia  the  pains  appear  in  the  form  of 
attacks  lasting  only  several  hours  and  alternating 
with  complete  euphoria. 

Ulcer  of  the  stomach  occasionally  presents  much 
more  similarity  to  the  affection  under  consideration. 
The  characteristic  signs  of  ulcer  (a  circumscribed  spot 
in  the  gastric  region  or  to  the  left  of  the  eleventh  to 
twelfth  dorsal  vertebra,  very  painful  on  pressure,  the 
aggravation  of  the  pains  after  the  ingestion  of  food, 
especially  of  coarse  substances,  a  preceding  hemor- 
rhage) will,  if  present,  make  the  differential  diagnosis 
between  this  affection  and  idiopathic  gastralgia  very 
easy.  Sometimes,  however,  all  of  the  characteristic 
symptoms  mentioned  are  absent,  and  then  it  becomes 
very  difficult  to  distinguish  between  these  two  affec- 
tions, for  there  undoubtedly  exist  ulcers  of  the 
stomach  which  give  rise  to  more  or  less  periodic 
paroxysms.  In  these  doubtful  cases  it  is  advisable  to 
institute  the  Ziemssen-Leube  rest  treatment  of  ulcer, 
and  if  this  proves  beneficial  it  will  speak  in  favor  of 
the  affection  having  been  an  ulcer ;  the  failure  of  this 
treatment  would  rather  tend  to  indicate  that  the 
affection  is  nervous  gastralgia. 

Stenosis  of  the  pylorus  is  accompanied  with  typical 
attacks  of  gastralgia.  When  frequent  vomiting  and 
ischochymia  are  present,  the  differential  diagnosis  is 
not  difficult.  If,  however,  the  two  symptoms  men- 
tioned are  absent,  it  may  sometimes  become  quite 
difficult  to  decide  between  the  two  conditions. 

In  diagnosticating  nervous  gastralgia,  it  will 
be  still  more  important  to  differentiate  between 
some  functional  disorders  of  the  stomach  which  may 


GASTRALGIA.  411 

be  associated  with  pains.  Such  affections  are:  (a) 
Hyperchlorhydria ;  (b)  periodic  and  chronic  continuous 
hypersecretion ;  (c)  achyha  gastrica.  In  hyperchlorhy- 
dria and  hypersecretion  the  pains,  as  a  rule,  disappear 
after  the  ingestion  of  food,  and  even  a  severe  attack 
may  be  checked  by  the  taking  of  some  food.  In 
achylia  gastrica  the  pains  exist  only  while  there  is  food 
in  the  stomach,  but  not  in  its  empty  condition,  while 
in  nervous  gastralgia  the  pains  appear  independently 
whether  there  be  food  in  the  stomach  or  not.  Besides 
these  clinical  symptoms  in  all  of  the  functional  dis- 
orders just  mentioned,  the  exact  diagnosis  can  be 
made  by  the  results  of  the  examination  of  the  gastric 
contents. 

There  are  other  conditions  which  also  provoke  pains 
in  the  gastric  region,  which  are  not  due  to  the 
stomach. 

Muscular  pains  of  the  abdomen,  due  either  to  rheu- 
matism or  to  overexertion,  may  give  rise  to  mistakes 
in  diagnosis.  The  pain  in  these  affections,  however, 
does  not  appear  paroxysmally  and  disappears  if  due  to 
overexertion  when  the  patient  assumes  a  recumbent 
position  and  the  abdomen  is  relaxed. 

Neuralgia  of  the  lower  intercostal  nerves  is  char- 
acterized by  extreme  sensitiveness  on  pressure  in  a 
certain  intercostal  space,  extending  forward  from  the 
vertebral  column ;  the  pain  is  more  superficial  than  in 
gastralgia. 

Gall  stones  frequently  give  rise  to  attacks  of  intense 
pains  which  may  be  mistaken  for  gastralgia.  When- 
ever there  is  a  distinct  history  of  cholelithiasis  (a  pre- 
ceding icterus,  the  appearance  of  gall  stones  in  the 


412  DISEASES   OF   THE   STOMACH. 

stools,  swelling  of  the  liver)  the  diagnosis  is  easy 
When,  however,  these  characteristic  symptoms  are 
absent,  then  it  becomes  more  difficult  to  differentiate 
between  gastralgia  and  biliary  colic.  The  following 
points  will  help  to  establish  the  differential  diagnosis. 
In  gall  stones  the  attack  of  pain  is  frequently  associated 
with  a  rise  of  temperature.  The  jjains  are  also  felt 
more  intensely  to  the  right  of  the  abdominal  cavity 
(liver).  In  gastralgia  there  is,  as  a  rule,  no  fever  and 
the  pains  on  the  right  side  are  not  so  well  marked  as 
in  biliary  colic.  In  many  instances  the  diagnosis  be- 
tween gastralgia  and  biliary  colic  will  remain  doubt- 
ful, and  it  is  then  advisable  to  institute  a  treatment 
which  would  be  suitable  for  gall  stones.  The  success 
or  the  failure  of  the  treatment  will  aid  in  the  estab- 
lishment of  the  correct  diagnosis. 

Enteralgia  or  intestinal  colic  is  characterized  by  the 
change  of  the  site  of  the  pains  from  one  place  to  an- 
other in  the  abdominal  cavity,  while  in  gastralgia  the 
pain  is  fixed  at  one  and  the  same  area.  Another  point 
in  the  differential  diagnosis  between  these  two  condi- 
tions is  the  circumstance  that  in  enteralgia  the  pain  is 
either  relieved  or  disappears  entirely  after  the  passage 
of  flatus.  Furthermore,  enteralgia  is  very  often  the 
result  of  irregularities  of  the  bowels,  and  the  condition 
is  therefore  ameliorated  after  these  have  been  regu- 
lated. 

Eenal  calculi  may  also  give  rise  to  colicky  pains. 
These  are  characterized,  however,  by  radiation  along 
the  ureter  to  the  bladder.  The  passage  of  a  small 
stone  or  of  gravel  or  of  blood  clots  with  the  urine  will 
easily  establish  the  true  nature  of  the  condition. 


GASTKALGIA.  413 

Treatment. — In  treating  a  case  of  gastralgia  it  is  of 
the  utmost  importance  to  recognize  the  primary  cause 
of  this  condition.  Thus  in  gastralgia  of  malarial 
origin  quinine  in  large  doses  will  be  the  best  remedy, 
while  in  that  due  to  chronic  nicotine  poisoning  a  cure 
will  be  obtained  by  forbidding  the  patient  to  smoke. 
Gastralgia  resulting  from  chlorosis  will  have  to  be 
treated  by  the  administration  of  iron,  arsenic,  bone 
marrow,  and  other  blood-producing  substances.  Gas- 
tralgia due  to  hysteria  and  neurasthenia  should 
be  treated  by  hydropathic  methods,  massage,  and 
large  doses  of  bromides.  Primary  gastralgia,  or  gas- 
tralgia in  which  no  etiological  factors  can  be  found,  is 
best  treated  by  the  application  of  the  galvanic  current, 
either  percutaneously  or  by  the  intraventricular 
method.  The  latter  mode  of  treatment  I  consider 
much  superior.  I  would  emphasize  that  methodical 
application  of  the  galvanic  current  intraventricularly, 
administered  for  a  period  of  from  four  to  six  weeks, 
rarely  fails  to  relieve  the  most  intense  and  obstinate 
cases  of  idiopathic  gastralgia. 

All  the  methods  of  treatment  just  mentioned  have 
in  view  the  prevention  of  the  attacks.  The  gastric 
attacks  as  such,  however,  should  be  treated  in  the 
following  manner.  Pains  in  the  abdomen  not  very 
intense  in  character  are  frequently  relieved  by  the 
application  of  a  hot-water  bag  or  a  warm  linseed 
poultice,  or  by  the  assumption  of  a  recumbent  posi- 
tion, and  the  taking  of  warm  drinks.  Hoffman's  ano- 
dyne (ten  to  twenty  drops)  in  sugar  water  or  on  a 
lump  of  sugar,  or  tincture  of  valerian  (fifteen  to 
twenty  drops)  may  also  relieve  the  pain.     If  the  at- 


414  DISEASES   OF   THE   STOMACH. 

tacks  of  gastralgia,  however,  appear  in  intense  form, 
the  administration  of  an  opiate  can  seldom  he  avoided. 
The  best  and  quickest  way  to  relieve  the  suffering  is 
a  hypodermic  injection  of  morphine  (one-sixth  to  one- 
fourth  of  a  grain) ;  sujDpositories  of  either  codeine  or 
opium  in  combination  with  belladonna  are  very  use- 
ful. I  frequently  prescribe  suppositories  of  two-thirds 
of  a  grain  of  opium  and  one-sixth  of  a  grain  of  bella- 
donna extract,  to  be  taken  every  two  or  three  hours 
until  the  pains  cease. 

Motor  Neuroses. 

Physiologically  as  soon  as  food  has  been  swallowed 
and  has  passed  the  pharynx,  the  further  motion  of  the 
bolus  is  accomplished  without  our  consciousness. 
We  know  from  experience  that  the  peristaltic  action 
of  .the  oesophagus  carries  the  bolus  to  the  cardia, 
which  has  opened  during  deglutition,  and  through  it 
to  the  stomach.  The  cardia  apparently  remains 
closed,  if  not  all  the  time,  then  at  least  when  the 
stomach  is  at  work.  The  pylorus  is  also  closed  during 
the  act  of  gastric  digestion,  and  opens  at  certain  inter- 
vals, in  order  to  allow  portions  of  chyme  to  pass.  The 
cardia  and  pylorus  being  closed,  the  anakinesic  work 
of  the  stomach  can  go  on  without  difficulty.  If  one 
of  the  arrangements  just  mentioned  is  disturbed,  then 
pathological  conditions  arise.  They  may  consist  either 
in  an  exaggerated  action  or  in  a  marked  diminution 
of  the  work  of  one  of  the  above  functions. 


SPASM   OF   THE    CARDIA.  4]  5 

Spasm  of  the  Carclia  (Cardiospasmus). 

Cardiospasmus  represents  a  condition  in  which  there 
is  a  spasmodic  contraction  of  the  cardia  and  the  lower 
part  of  the  oesophagus,  causing  pain  and  d3'sphagia, 
and  not  dependent  upon  an  anatomical  lesion. 

Symptomatology. — Although  chewing  and  swallow- 
ing food  is  accomplished  without  difficulty,  as  soon  as 
a  few  mouthfuls  have  heen  ingested  a  feeling  of  pres- 
sure is  experienced  in  the  region  of  the  upper  and 
middle  portions  of  the  sternum.  The  patient  feels  as 
if  something  had  remained  in  the  oesophagus.  At  the 
same  time  he  has  also  a  slight  sensation  of  dyspnoea. 
Instinctively  the  inspirations  now  become  much 
deeper  and  the  expirations  are  performed  with  much 
force.  The  latter  act  frequently  causes  a  regurgita- 
tion of  the  oesophageal  contents.  As  soon  as  the 
oesophagus  has  become  empty  in  this  way  the  patient 
feels  better  and  the  symptoms  just  described  disap- 
pear. The  same  phenomena  come  into  play  as  often 
as  the  patient  begins  to  eat. 

Cardiospasmus  may  ajDpear  in  an  acute  form  and 
last  only  a  very  short  time  (one  to  two  days),  or  it 
may,  in  rare  instances,  exist  as  a  chronic  affection 
and  last  for  many  years.  In  the  latter  instance  it 
must  always  be  considered  as  a  grave  trouble.  The 
chronic  form,  although  originally  based  on  the  same 
derangements,  manifests  itself  in  a  somewhat  dif- 
ferent way  from  the  acute  variety.  The  same  diffi- 
culties (dysphagia)  are  experienced  as  described  above 
after  the  swallowing  of  food.  Instead  of  regurgitat- 
ing the  food,  however,  the  patient  instinctively  learns 


410  DISEASES   OF  THE   STOMACH. 

to  force  it  down  into  the  stomach,  taking  a  very  deep 
inspiration  and  compressing  the  thorax  by  muscular 
action  while  holding  his  breath.  Liquid  and  semi- 
liquid  foods  are  easily  forced  down  into  the  stomach  in 
the  manner  just  described.  Most  of  the  patients  learn 
to  ingest  even  coarse  substances;  they  are  obliged, 
however,  to  take  a  few  mouthfuls  of  liquid  before 
they  can  pass  the  food  into  the  stomach.  As  a  rule, 
in  all  these  cases  of  chronic  cardiospasmus  the  upper 
part  of  the  oesophagus  becomes  dilated,  and  can  easily 
hold  from  300  to  -iOO  c.c.  That  is  the  reason  why 
patients  aJHicted  with  this  trouble  perform  the  act  of 
forcing  the  food  farther  down,  not  after  every  one  or 
two  mouthfuls,  but  rather  after  having  already  taken 
quite  a  considerable  quantity,  as  the  food  meanwhile 
can  easily  lodge  within  the  oesophagus.  As  a  rule, 
three  or  four  intermissions  are  made  by  the  patient 
during  a  meal  in  order  to  force  the  food  into  the 
stomach. 

In  some  cases  the  dysphagia  is  more  pronounced  on 
certain  days,  and  less  on  others.  Such  patients  are 
occasionally  able  to  take  an  ordinary  meal  without  the 
slightest  difiSculty.  As  a  rule,  however,  these  good 
days  are  not  numerous.  The  explanation  for  this 
variable  condition  lies  in  the  assumption  that  the  spas- 
modic contraction  of  the  cardia  alternates  with  periods 
of  relaxation.  These  periods  of  relaxation,  however, 
are  found  only  in  cases  which  are  not  of  long  stand- 
ing. If  the  condition  has  lasted  for  a  considerable 
length  of  time  (one  or  two  years),  a  dilatation  of  the 
oesophagus  is  often  the  result.  As  soon  as  this  has 
occurred,  the  dysphagia  becomes  permanent,  no  mat- 


SPASM   OF  THE   CARDIA.  417 

ter  whether  the  cardia  be  spasmodically  contracted 
or  not.  The  same  condition — viz.,  dilatation  of  the 
oesophagus — can  also  be  produced,  either  by  paralysis 
of  the  oesophagus  or  by  a  lack  of  reflex  relaxation  of 
the  cardia  (or  paralysis  of  the  nervus  dilatator  car- 
dise,  Oppenchowski).  After  dilatation  of  the  oesopha- 
gus has  been  established  it  is  generally  most  difficult  to 
decide  whether  this  is  a  result  of  a  spasmodic  contrac- 
tion of  the  cardia  or  of  one  of  the  two  conditions  just 
mentioned.  The  following  case  *  well  illustrates  the 
latter  possibility : 

J.   W ,   45  years  of  age,   janitor,   had  typhoid 

fever  twenty-five  years  ago,  since  which  time  he  has 
enjoyed  perfect  health.  In  the  beginning  of  March, 
1888,  the  patient  fell  dov/n  in  the  street,  striking  his 
back  against  a  small  projection.  He  arose  unaided, 
and  resumed  his  work  without  any  annoyance.  On 
the  following  day  he  had  pains  in  the  upper  part  of 
his  body,  especially  in  his  arms ;  these  lasted  but  a  few 
days  and  disappeared. 

About  fourteen  days  later  the  patient  began  to  have 
a  feeling  of  fulness  after  eating,  and  had  a  pressing 
sensation  above  the  gastric  region.  Two  or  three 
weeks  later  he  noticed  some  difficulty  in  taking  his 
food,  and  tried  to  assist  it  by  drinking  warm  water 
several  times  during  the  meal ;  only  in  this  way  did 
he  succeed  in  enjoying  a  whole  meal. 

In  May,  on  account  of  this  pressing  sensation,  the 
patient  was  compelled  to  leave  the  table  in  the  middle 
of  a  meal  and  walk  up  and  down  the  room,  making 

'  Max  Einhorn  :  "  A  Case  of  Dysphagia  with  Dilatation  of  the 
(Esophagus,"  Medical  Record,  1888.  Similar  oases  have  been  de- 
scribed by  S.  J.  Meltzer  :  Berl.  klin.  Wochenschr.,  1888,  No.  8,  and  J. 
May  ban  m  :  Archiv  fiir  Verdaunngskrankheiten,  Bd.  i..  Heft  4. 

27 


418  DISEASES   OF  THE   STOMACH. 

deep  inspirations  and  expirations;  he  used  to  press 
with  his  hands  upon  the  front  of  the  lower  part  of  his 
thorax  after  having  made  a  deep  inspiration  and  closed 
the  glottis.  The  patient  said  that  these  attacks  dur- 
ing a  meal  resembled  very  much  a  suffocating  condi- 
tion. The  described  manipulation  usually  brought 
him  relief,  allowing  him  to  eat  again,  but  then  the 
process  repeated  itself.  In  the  morning  he  could  eat 
more  easily  than  at  noon-time. 

Since  June,  18SS,  the  patient  has  been  sleeping  very 
badly  (at  most  three  hours  during  the  night).  When 
in  bed  he  had  often  a  sensation  as  if  something  would 
go  up  and  down  in  the  interior  of  his  chest,  and  when 
this  sensation  came  on  he  was  forced  to  cough  quite 
often.  From  time  to  time  it  happened  that  he  awoke, 
his  mouth  being  full  of  fluid ;  also  while  awake  some 
fluid  at  times  came  up  into  his  throat  and  mouth,  this 
only  happening  when  in  the  recumbent  position. 
When  standing,  he  was  never  compelled  to  empty 
his  throat. 

The  patient  became  thin,  felt  weak  and  miserable, 
and  soon  could  j^artake  only  of  fluid.  The  sight  of 
solid  food  enraged  him  to  such  a  degree  that  he  threw 
it  away  with  disgust.  Even  fluid  substances  were 
taken  only  with  great  difficulty;  he  used  to  throw  his 
arms  backward,  and,  standing  erect,  his  head  leaning 
toward  the  back,  after  a  deep  inspiration  and  with 
closed  glottis  he  would  press  firmly.  The  condition 
of  the  patient  became  worse  and  worse ;  he  lost  forty- 
one  pounds  during  these  few  months,  and  went  for 
aid  to  the  German  Dispensary  on  October  23d,  1888. 

Present  Condition. — October  23d,  1888 :  Patient  tall 
in  stature  and  lean  ;  looks  pale.  The  integument  can  be 
lifted  in  large  folds.  The  physical  examination  of  the 
thorax  and  the  abdomen  cannot  detect  anything  ab- 
normal.    The  heart  sounds  are  normal.     Pulse,    To; 


SPASM   OF   THE    CARDIA.  419 

respiration,  20 ;  temperature,  judging  from  sensation 
upon  the  chest,  not  increased.  The  patellar  reflex  is 
present,  and  the  patient  is  able  to  stand  with  eyes 
closed.  The  urine  does  not  contain  any  sugar  or 
albumin.  The  patient  complains  of  not  being  able  to 
eat  any  solid  food,  and  of  difficulty  in  taking  even 
fluids,  as  he  cannot  get  them  down.  Besides  this,  he 
has  nearly  always  a  pressing  sensation  around  the 
chest,  coughs  very  much,  and  is  not  able  to  sleep  well. 

Examination  of  the  Stomach  and  CEsophagus. — 1. 
October  2oth,  1888,  at  8  a.m.  :  Patient  drank  coffee 
one  hour  before.  As  soon  as  a  part  of  the  stomach 
tube  was  pushed  into  the  oesophagus  a  coffee-brown 
liquid  was  ejected,  in  which  there  were  some  rem- 
nants of  food  and  many  epithelial  cells  present.  The 
patient  then  drank  100  c.c.  water.  I  did  not  hear  any 
swallowing  sound  at  the  ensiform  process  during  the 
time  that  the  patient  drank.  On  introducing  a  part 
of  the  tube  into  the  oesophagus,  water  of  a  neutral 
reaction  came  out.  Thereupon  the  tube  was  pushed 
farther  into  the  stomach  without  any  resistance,  and 
the  patient  ejected  from  his  stomach  through  the  tube 
about  YO  c.c.  of  a  coffee-brown  liquid.  Eeaction  acid, 
hydrochloric  acid  present  (phloroglucin-vanillin  test), 
the  degree  of  acidity  being  40. 

2.  November  5th,  at  9  a.m.  :  On  account  of  loss  of 
appetite,  the  patient  had  not  eaten  anything  since  2 
P.M.  of  the  previous  day.  The  tube  was  introduced 
for  a  length  of  46  cm.  from  the  teeth;  a  pulpy  mass 
(150  c.c.)  came  out,  in  which  were  present  small  par- 
ticles of  bread;  reaction  acid,  lactic  acid  present,  no 
hydrochloric  acid ;  acidity  =  4.  The  patient  drank 
100  c.c.  water,  the  tube  was  introduced  45  cm.,  the 
water  came  out  somewhat  turbid  by  the  admixture  of 
mucus  and  food  remnants ;  microscopically  there  were 
many  epithelial  cells  and  micrococci.     After  the  water 


420  DISEASES   OF   THE   STOMACH. 

had  come  out,  the  tube,  without  being  taken  out,  was 
pushed  farther  and  with  but  a  slight  resistance  it 
passed  into  the  stomach;  the  patient  was  told  to 
empty  his  stomach,  but  only  a  few  drops  of  clear  fluid 
were  obtained.  This  proved  that  the  stomach  was 
empty. 

3.  November  8th :  The  patient  partook  of  breakfast, 
and  then  drank  water;  he  was  examined  an  hour 
later.  The  tube  was  introduced  for  a  distance  of  36 
cm.,  when  there  appeared  a  fluid  containing  no  hy- 
drochloric acid;  thereupon  the  tube  was  pushed,  with- 
out any  further  resistance,  into  the  stomach,  and  by 
expression  a  fine  chyme  was  obtained  containing  hy- 
drochloric acid  and  peptone. 

4.  November  13th:  The  patient  took  eggs,  coffee, 
and  a  little  softened  white  bread;  then  he  adminis- 
tered his  method  of  bringing  the  food  down  into  the 
stomach  by  means  of  pressing  (bringing  the  muscles 
of  expiration  into  play,  after  having  made  a  deep  in- 
spiration, with  closed  glottis).  An  hour  later,  shortly 
before  the  examination,  the  patient  was  told  to  press 
several  times  again.  The  tube  was  introduced  to  a 
distance  of  48  cm.,  and  during  expiration  only  8  c.c. 
of  a  turbid  liquid  were  obtained ;  there  were  present 
very  minute  pieces  of  bread  and  many  epithelial  cells, 
but  no  hydrochloric  acid ;  thereupon  the  tube  was 
pushed,  without  any  resistance,  into  the  stomach ;  now 
there  came  out  a  chymous  fluid  with  hydrochloric 
acid.  The  patient  drank  200  c.c.  water;  the  tube 
was  introduced  about  40  cm.,  and  the  water  came  out 
with  a  gush. 

5.  November  16th:  Patient  took  breakfast  at  home 
and  administered  his  method  of  forcing  down  his 
food.  The  oesophagus  was  examined  an  hour  later 
and  found  empty.  The  pharyngeal  vault  was  tickled 
with  the  finger  to  induce  vomiting,  but  without  sue- 


SPASM   OF   THE   CARDIA.  421 

cess.  Thereupon  the  tube  was  iutroduced  into  the 
stomach,  and  a  fine  chymous  fluid,  containing  hydro- 
chloric acid,  was  obtained.  The  stomach  was  then 
filled  with  air  by  means  of  a  tube  and  bulb ;  the  air 
did  not  escape  along  the  outside  wall  of  the  tube.  By 
keeping  the  tube  open  the  stomach  was  emptied  of  the 
air;  afterwards  the  lower  part  of  the  oesophagus  was 
blown  up.  A  considerable  quantity  of  air  could  be 
blown  into  it  without  returning,  but  upon  increasing 
it  still  more  the  air  began  to  escape  upward  through 
the  upper  part  of  the  oesophagus,  along  the  outer  side 
of  the  tube  wall.  During  the  inflation  of  the  oesoph- 
agus there  was  observed,  at  both  sides  of  the  vertebrae 
below  the  inferior  margin  of  the  scapulae,  somewhat 
more  tympanitic  resonance,  but  that  was  not  very 
decided. 

It  is  evident,  from  the  history  of  this  patient,  that 
the  difficulty  in  bringing  the  food  into  the  stomach 
slowly  developed  a  few  days  after  the  fall,  and  finally 
led  to  complete  dysphagia.  The  examinations  showed 
that  the  contents  of  the  stomach  were  normal.  The 
examinations  with  the  stomach  tube  show,  firstly, 
that  the  passage  through  the  oesophagus  to  the 
stomach  is  perfectly  free,  for  the  thick  tube  passed 
into  the  stomach  without  any  resistance;  secondl}^, 
that  the  oesophagus,  in  its  lower  third,  must  be  sac- 
cularly  dilated,  as  the  distance  from  the  teeth  to  the 
cardia  (measured  with  the  tube)  is  48  cm. ;  whereas 
in  the  case  of  this  patient,  even  taking  into  considera- 
tion his  large  frame,  it  ought  normally  to  be  not  more 
than  40  to  41  cm.  In  this  cavity  the  tube,  leaning  on 
the  wall  of  the  oesophagus,  was  compelled  to  assume 
with  its  lower  end  the  form  of  a  semicircle,  and  thus 
produce  this  high  figure.  That  the  patient  is  really 
unable,  in  swallowing,  to  bring  even  liquids  down  to 
his  stomach,  except  by  the  pressing  action,  is  proven 


422  DISEASES   OF   THE   STOMACH. 

by  the  fact  that  swallowed  water  could  always  he 
taken  out  from  the  oesophagus  by  means  of  the  tube, 
whereas  immediately  afterward  the  tube,  pushed  into 
the  stomach,  brought  up  part  of  the  stomach  contents 
containing  hydrochloric  acid. 

Ewald  mentions  a  similar  case,  in  which  the  tube 
passed  into  the  stomach  without  encountering  any 
resistance  at  the  cardia  while  the  food  still  remained 
within  the  oesophagus.  He  considers  this  case  as  one 
of  spasmodic  contraction  of  the  cardia  and  believes 
that  although  no  resistance  was  felt  with  the  tube, 
still  the  cardia  became  contracted  during  deglutition. 
I  do  not  think  it  is  necessary  to  assume  that  the  cardia 
acts  differently  during  insertion  of  the  tube  than 
while  taking  food.  As  I  remarked  above,  the  symp- 
tom of  dysphagia  exists  as  soon  as  dilatation  of  the 
oesophagus  has  been  established,  no  matter  whether 
the  cardia  be  contracted  or  not,  for  the  dilated  oesoph- 
agus cannot  contract  sufficiently  to  carry  the  food  into 
the  stomach.  In  order  to  accomplish  this,  other 
means  will  be  necessary,  consisting,  as  mentioned 
above,  in  the  compression  of  the  thorax,  after  a  deep 
inspiration. 

Diagnosis. — The  diagnosis  of  the  acute  form  of  car- 
diospasmus  is  based  upon  the  following  points:  The 
existence  of  dysphagia  for  a  short  time,  the  absence 
of  the  swallowing  sounds,  and  the  resistance  encoun- 
tered at  the  cardia  on  insertion  of  a  tube  into  the 
oesophagus — a  resistance,  however,  which  can  be  over- 
come. It  is  characteristic  of  this  spasmodic  contrac- 
tion of  the  cardia  that  the  resistance  felt  during  the 
introduction  of  different-sized  bougies  is  the  same  or 


SPASM   OF    THE    CARDIA.  423 

rather  less  for  those  of  large  calibre,  while  in  organic 
strictures  of  the  cardia  a  thick  tube  is  unable  to  pass 
and  the  thin  ones  encounter  either  no  resistance  at  all 
or  glide  through  with  some  resistance.  The  diagnosis 
of  the  chronic  forms  of  cardiospasmus  can  be  made  if 
the  symptom  of  dysphagia  has  lasted  for  long  periods 
of  time  (three  months  to  two  years;  and  the  examina- 
tion with  a  bougie  reveals  the  same  condition  as  de- 
scribed in  the  acute  form. 

Dilatation  of  the  oesophagus,  which  is  of  so  frequent 
occurrence  in  this  affection,  and  its  most  important 
sequelae  can  be  diagnosed  in  the  following  way :  The 
patient  one  to  two  hours  after  a  meal  is  examined  by 
means  of  a  tube,  which  is  introduced  into  the  oesopha- 
gus, and  if  there  be  some  contents  (in  the  oesophagus) 
they  are  withdrawn.  The  patient  now  drinks  a  glass- 
ful of  water  (200  to  300  c.c.)  and  is  told  not  to  perform 
the  forcing  motions.  After  an  interval  of  about  five 
minutes  the  tube  is  again  inserted  into  the  oesophagus. 
If  dilatation  of  the  latter  exists,  the  water  will  now 
appear  through  the  tube  in  about  the  same  condition 
as  when  drank,  i.e.,  not  mixed  with  food.  On  push- 
ing the  tube  farther  down  through  the  cardia  into 
the  stomach,  real  gastric  contents  will  now  appear, 
showing  that  the  water  the  patient  drank  had  re- 
mained all  the  time  within  the  oesophagus  and  had 
not  mixed  with  the  food. 

Prognosis. — The  prognosis  of  the  acute  form  is 
good.  That  of  the  chronic  form  is  good  quoad  vitam 
and  bad  quoad  valetudinem  completam. 

Treatment. — The  acute  form  is  best  treated  by  large 
doses  of  bromides  and  bv  the  introduction  of  large- 


424  DISEASES   OF   THE   STOMACH. 

sized  sounds.  Opiates  and  chloral  hydrate  have  also 
sometimes  a  beneficial  effect.  In  the  chronic  form, 
the  treatment  will  consist  in  the  following;  1.  The 
patient  is  allowed  to  take  only  fluid  or  semi-fluid 
foods;  2.  After  every  meal  he  must  perform  his  press- 
ing action  for  a  long  time ;  3.  Every  evening,  before 
going  to  bed,  the  oesophagus  is  emptied  and  washed 
by  means  of  the  tube;  -4.  The  patient  introduces  the 
tube  into  his  stomach  once  every  day,  in  order  to  relax 
the  cardia.  After  a  while,  when  the  patient  feels 
better,  he  can  begin  to  introduce  greater  variety  into 
his  diet,  and  is  allowed  to  eat  even  solid  substances. 

Eructation. 

The  frequent  expulsion  of  gas  from  the  stomach 
through  the  mouth  is  known  as  eructation  or  belch- 
ing. While  this  condition  may  accompany  the  most 
varied  affections  of  the  stomach,  it  may  also  occur 
alone  and  is  then  considered  as  a  neurosis.  It  is 
characteristic  of  the  latter  that  the  gas  expelled  has 
no  particular  odor  and  consists  principally  of  air. 
The  eructations  of  gas  may  appear  in  the  form  of  at- 
tacks lasting  half  an  hour  to  an  hour  or  much  longer. 
The  intervals  between  the  eructations  during  an  at- 
tack are  sometimes  very  short,  so  that  there  may  occur 
two  or  three  belching  spells  in  one  minute.  Some- 
times the  expelled  gas  does  not  come  from  the  stom- 
ach, but  merely  from  the  oesophagus,  and  consists  of  air 
which  has  just  been  swallovv'ed  previous  to  the  l)elch- 
ing.  Some  people  are  able  to  produce  this  kind  of 
belching  voluntarily.     Ewald  states  that  he  can  belch 


ERUCTATION.  425 

at  will  from  the  oesophagus.  By  auscultating  himself 
to  the  ensiform  process,  he  became  conviuced  that  the 
air  voluntarily  eructated  did  not  come  from  his  stom- 
ach, as  no  sound  whatever  was  audible  at  the  ensiform 
process.  In  view  of  this  fact  and  of  the  importance 
of  swallowing  of  air  in  the  production  of  belching, 
Bouveret '  proposed  to  designate  this  condition  as  aei^o- 
phagia  (eating  of  air) .  I  am  inclined  to  think  that 
the  frequent  eructations  from  the  oesophagus,  w^hich 
are  always  preceded  by  acts  of  deglutition  and  accom- 
panied by  loud  sounds,  are  identical  with  singultus, 
and  result  from  a  condition  of  irritation  of  the  phrenic 
nerves.  Attacks  of  singultus  of  short  duration  (ten 
to  fifteen  minutes)  are  of  frequent  occurrence,  while 
attacks  lasting  several  days  without  interruption  are 
quite  rare.  The  latter  occur  either  accompanying 
very  grave  conditions  (cancer  of  the  stomach  and  some 
cases  of  peritonitis)  or  again  as  a  primary  neurosis. 
Nervous  belching  may  either  last  several  days  or  exist 
for  years.  The  patients  are  never  disturbed  by  the 
act  of  belching  during  sleep,  but  in  the  daytime  the 
trouble  may  sometimes  be  so  annoying  as  to  keep  them 
away  from  society  or  even  from  business.  The  act  of 
belching  is  ascribed  by  some  to  an  increased  peristaltic 
action  of  the  stomach,  by  some  to  a  decreased  contrac- 
tion or  a  relaxation  of  the  cardia,  and  by  some  to  both 
of  these  conditions  together. 

Etiology. — Nervous  belching  is  frequently  found  in 
hysterical  and  neurasthenic  persons,  but  also  in  people 
not  otherwise  showing  any  neurotic  symptoms  what- 
ever.    It  sometimes  appears  after  great  mental  worry 
'  Bouveret :  I.  c,  p.  611. 


426  DISEASES   OF   THE   STOMACH. 

or  excitement,  or  also  as  a  sequel  of  an  acute  gastric 
catarrh. 

Treatment. — In  persons  with  a  weakened  constitu- 
tion, in  neurasthenics  and  hysterical  persons,  this 
primary  trouble  must  be  treated  as  such.  If  the  con- 
dition is  idiopathic,  the  administration  of  the  bromide 
salts  is  very  valuable.  The  faradic  current  applied 
intraventricularly  has  given  me  very  good  results  in 
this  class  of  cases.  Diet  does  not  seem  to  have  much 
influence  upon  the  affection.  I  deem  it  very  impor- 
tant to  tell  the  jDatient  to  try  and  suppress  the  belch- 
ing as  often  as  he  can.  Very  frequently  this  measure 
alone  suffices  to  effect  a  cure. 

Pyrosis. 

By  the  term  pyrosis  is  designated  the  ejection  of 
chyme  from  the  stomach  into  the  oesophagus.  As  a 
rule,  a  burning  sensation  is  then  felt  at  the  pit  of  the 
stomach,  which  is  also  known  under  the  name  of 
heartburn.  While  pyrosis  is  of  frequent  occurrence 
in  hyperchlorhydria,  it  may  also  appear  as  a  neurosis 
even  if  the  gastric  secretion  is  perfectly  normal.  It 
is  generally  believed  that  the  sensation  of  heartburn 
can  be  produced  solely  by  acid  fluids,  but  the  sensa- 
tion can  exist  even  without  the  presence  of  an  acid. 
Thus  I  have  at  present  under  observation  a  patient 
with  achylia  gastrica,  in  whom  the  gastric  contents 
are  almost  always  of  a  neutral  reaction  and  who 
nevertheless  frequently  complains  of  heartburn. 


REGURGITATION.  42? 

Regurgitation. 

Eegurgitation  denotes  a  condition  in  which  either 
liquids  or  liquids  mixed  with  solid  food  particles  are 
ejected  in  small  portions  from  the  stomach  into  the 
mouth.  These  contents  are,  as  a  rule,  spit  out;  occa- 
sionally, however,  they  are  again  swallowed.  It  is 
generally  believed  that  a  relaxation  of  the  cardia  is 
the  cause  of  the  trouble.  In  most  instances  regurgi- 
tation takes  place  involuntarily,  in  some,  however, 
the  patient  is  able  to  produce  it  at  will.  In  nervous 
regurgitation  the  ejected  matter  does  not  show  any 
abnormal  condition  (and  does  not  smell  or  taste  bad). 
This  is  different  if  regurgitation  is  the  result  of  an 
organic  affection  of  the  stomach.  Eegurgitation,  as 
a  rule,  appears  soon  after  meals,  and  this  process  may 
repeat  itself  quite  a  number  of  times  in  a  short  period. 
In  most  instances  this  affection  does  not  lead  to  any 
serious  conditions.  Sometimes,  however,  if  regurgi- 
tation is  very  obstinate  and  large  portions  of  chyme 
are  constantl}'  ejected,  serious  complications  may  re- 
sult from  inanition. 

The  following  case,  which  I  have  observed,  is  inter- 
esting with  regard  to  this  point. 

A  boy,  8  years  of  age,  had  been  suffering,  as  his 
mother  stated,  from  obstinate  vomiting  for  about 
three  years.  The  little  patient  looked  extremely  pale 
and  emaciated.  He  had  cold  extremities,  became 
dizzy  quite  frequently,  especially  on  rising,  and  felt 
very  weak,  so  that  a  walk  of  two  blocks  tired  him  out. 
On  further  inquiry  the  mother  stated  that  the  boy  did 
not  vomit  a  large  quantity  at  once,  but  brought  up 


428  DISEASES   OF   THE   STOMACH. 

small  portions  of  food  from  the  stomach  which  he  spat 
out.  This  occurred  fifteen  to  twenty  or  even  more 
times  after  each  meal.  Physical  examination  of  the 
chest  revealed  nothing  abnormal.  The  abdomen  was 
slightly  bloated ;  the  splashing  sound  could  be  pro- 
duced in  the  gastric  region,  extending  to  two  fingers' 
width  below  the  navel.  On  palpation  no  painful 
spots  could  be  discovered.  The  patient  took  a  small 
meal  and  was  observed  half  an  hour  afterward.  Ee- 
gurgitation  took  place  while  he  was  in  ray  office.  The 
ejected  chyme  revealed  on  examination  the  presence 
of  free  hydrochloric  acid  in  normal  amounts.  The 
case  was  diagnosed  as  nervous  regurgitation,  and  the 
extreme  degree  of  anaemia  and  malnutrition  referred 
to  insufficient  nutrition  on  account  of  the  great 
amount  of  chyme  which  was  constantly  ejected  from 
the  stomach  and  in  this  way  lost  to  the  organism. 
The  little  patient  was  given  no  medicine,  but  was  told 
never  to  spit  out  the  food  which  came  up  into  his 
mouth,  but  rather  to  swallow  it.  The  mother  was 
told  to  keep  constant  watch  over  the  boy,  in  order  to 
have  this  rule  strictly  observed.  In  about  three 
months  the  patient  began  to  grow  stronger  and  gained 
in  weight,  so  that  after  this  time  he  could  hardly  be 
'considered  sick.  Moreover,  regurgitation  now  ap- 
peared quite  seldom  and  was  then  repeated  only  once 
or  twice. 

Etiology. — Eegurgitation  may  develop  either  in 
consequence  of  great  mental  worry  or  nervous  strain 
or  as  a  sequel  of  an  acute  gastric  catarrh. 

The  prognosis  is  almost  always  good. 

Treatment. — This  consists  in  the  application  of  the 
faradic  current  intraventricularly  and  in  the  adminis- 
tration  of   strychnine.      In  conjunction    with    these 


RUMINATION.  429 

remedies,  the  patient  must  be  told  to  suppress  regur- 
gitation whenever  possible.  At  first  he  will  often 
fail  to  do  so.  but  after  a  while  he  will  be  able  to  sup- 
press it,  and  still  later  the  tendency  to  regurgitation 
will  entirely  disappear.  In  cases  in  which  regurgita- 
tion is  of  frequent  occurrence  and  obstinate,  and 
nutrition  begins  to  be  insuflScient,  it  is  of  the  greatest 
importance  to  forbid  the  patient  to  spit  out  the  ejected 
food  and  to  tell  him  to  swallow  it  again.  This  treat- 
ment may  occasionally  artificially  produce  the  condi- 
tion which  will  now  be  described. 

Rumination.^ 

Synonyms. — Merycism,  "chewing  the  cud." 
By  rumination  is  designated  a  condition  in  which 
the  food  returns,  without  nausea,  in  small  portions, 
from  the  stomach  through  the  oesophagus  into  the 
mouth,  some  time  after  meals;  here  it  is  chewed 
anew  and  swallowed. 

Etiology. — If  we  are  not  inclined  to  accept  as  the 
cause  of  rumination  an  anatomical  alteration  in  the 
upper  digestive  tract — a  hypothesis  not  demonstrated 
or  even  rendered  probable — two  explanations  still  pre- 
sent themselves,  namely,  heredity  and  self-acquisition. 
But  as  heredity  has  been  met  with  in  only  very  few 
cases  of  rumination,  and  thus  cannot  be  taken  for  the 
main  cause  of  the  affection,  it  appears  of  importance 
to  lay  most  stress  on  self -acquisition.  This  may  arise, 
firstly,  from  imitation;  secondly,  from  necessity  and 
custom  (adaptation). 

J  The  history  and  literature  of  this  affection  can  be  found  in  my 
paper:  "Rumination  in  Man,"  Medical  Record,  May  17th,  1890. 


430  DISEASES   OF   THE   STOMACH. 

As  the  best  example  of  imitation  Koerner's '  case 
may  be  cited,  where  a  ruminating  governess  imparted 
her  own  affection  to  her  two  pupils ;  after  the  gover- 
ness had  been  sent  away,  the  two  children  quickly 
got  rid  of  their  rumination. 

In  many  cases  of  rumination  the  patients  first,  be- 
fore the  beginning  of  the  trouble,  had  for  some  time 
suffered  from  dyspeptic  symptoms  with  regurgitations; 
thereafter  they  commenced  to  swallow  what  came  up 
by  regurgitation,  and,  finally,  were  aware  of  ruminat- 
ing. In  these  cases  the  development  of  rumination 
from  slight  pathological  conditions,  by  necessity  and 
custom,  can  be  plainly  seen. 

Most  of  the  reported  cases  of  rumination  (in  all  the 
literature,  to  date,  but  one  hundred  and  six  cases  have 
been  described)  are  of  the  male  sex,  and  belong  chiefly 
to  the  professional  and  more  educated  classes  (physi- 
cians, philologists,  and  lawyers) ;  of  the  female  sex 
only  a  few  cases  are  reported  as  ruminants  (in  all  nine 
cases,  figured  from  the  paper  of  Johannessen).' 

This  alone  would  not  prove  that  rumination,  in  fact, 
appears  less  frequently  in  men  of  the  lower  class  and 
in  the  female  sex;  for  very  often  a  man  of  the  work- 
ing class  does  not  deem  his  condition  as  a  ruminant 
to  be  abnormal,  and  does  not  make  mention  of  it  to 
his  physician.  On  the  other  hand,  there  are  several 
people  (especially  among  women)  who  would  like  to 
conceal  their  affection,  and  therefore  do  not  speak 
about  it.  In  consequence  thereof,  the  correct  relation 
of  rumination,  in  reference  to  its  distribution  among 

'Koerner:  Deutsch.  Arcli.  f.  klin.  MediciD,  Bd.  xxxiii.,  p.  554. 
'^  Joliannessen  :  Zeitschr.  f.  klin.  Medicin,  Bd.  x.,  p.  274. 


RUMINATION.  431 

the  two  sexes  and  the  different  social  classes,  cannot 
be  ascertained  from  the  cases  reported  in  literature. 

Among  the  insane  and  idiots  rumination  has  been 
found  quite  frequently.  Thus  G.  Cantarono  '  found 
nine  cases  of  rumination  among  four  hundred  male 
insane;  but  among  three  hundred  female  insane  he 
found  no  ruminants.  Bourneville  and  Seglas""  like- 
wise lay  stress  on  the  frequency  of  rumination  in 
idiots,  and  also  in  epileptics. 

Duration. — The  duration  of  merycism  is  very  vari- 
able;  sometimes  there  is  rumination  going  on  uninter- 
ruptedly during  the  whole  of  life.  Often  it  appears 
in  the  forms  of  attacks,  periods  of  rumination  alter- 
nating with  normal  periods  of  varying  duration. 

Sometimes  rumination  suddenly  ceases  at  the  occur- 
rence of  an  important  change  in  the  life  of  the  mery- 
cist.  Thus  a  case  is  on  record  in  which  a  person 
ceased  to  ruminate  immediately  after  marriage.  But 
there  is  also  a  report  of  another  case  in  which  rumina- 
tion made  its  appearance  a  day  after  marriage. 

These  varying  circumstances  can  only  prove  how 
deeply  rumination  is  connected  with  the  nervous 
functions. 

Chemical  Analysis  of  the  Stomach  Contents. — The 
investigations  upon  the  chemical  condition  of  the 
stomach  in  merycists  have  been  made  only  within  the 
most  recent  period. 

Johannessen  says  briefly,  in  his  elaborate  paper  on 
rumination,  that  at  the  end  of  rumination  the  ejected 

'G.  Cantarono:  Neurolog.  Centralbl.,  Bd.  iv. ,  1885. 
2  Bourneville  et  Seglas :    "  Du  Meryeisme. "   Arch,  de  Neurologie, 
Paris,  1883. 


4:32  DISEASES   OF   THE   STOMACH. 

materials  showed  an  acid  reaction.  Alt,'  in  1888, 
was  the  first  to  make  exact  examinations  of  the 
stomach  contents  in  a  ruminant.  As  soon  as  the 
patient  suppressed  rumination  it  was  found  that  the 
stomach  contents,  obtained  three  to  four  hours  after  a 
test  dinner,  contained  free  hydrochloric  acid,  were 
rather  hyperacid,  and  showed  very  retarded  amylolytic 
qualities.  But  as  soon  as  the  patient  had  practised 
his  rumination  as  usual,  the  stomach  contents  were 
less  acid  and  the  amylolysis  was  much  better.  Alt 
presumes  that  the  rumination  in  his  patient  had  the 
purpose  of  correcting  the  fault  made  by  a  deficient 
salivation  of  the  food  and  the  hyperacidity  arising 
from  it.  "We  would  seem  to  have,"  he  says,  "in 
rumination  a  process  for  correcting  the  hyperacidity 
caused  by  a  deficient  salivation  and  the  bad  digestion 
of  amylaceous  matters."  Acting  on  this  theory,  Alt 
treated  his  patient  with  alkalies,  with  the  result  that 
the  patient  was  less  inclined  to  ruminate,  and  further, 
could  suppress  the  habit  much  more  easily. 

In  favor  of  Alt's  theory  would  be  perhaps  the  case 
of  rumination  reported  by  W.  A.  Hubbard."  A 
farmer,  aged  thirty-five,  consulted  Dr.  Hubbard  for, 
as  he  expressed  it,  " the  restoration  of  his  lost  cud." 
This  patient  had  had  the  habit  of  ruminating  his  food 
since  a  period  beyond  his  recollection,  and  had  always 
enjoyed  perfect  health ;  now,  for  a  month  the  rumina- 
tion had  stopped,  and  this  was  immediately  followed 
by  dyspeptic  symptoms.  All  medicaments  proved  to 
be  of  no  use.     Should  we  look  with  Alt  upon  rumina- 

'Alt:  Berl.  klin.  Wochenschr.,  1888,  Nos.  26  and  27. 

2W.  A.  Hubbard:   Medical  Record,  July  31st,  1886,  p.  122. 


RUMINATION.  433 

tion  as  a  means  of  correctioD,  it  would  be  very  easy 
to  understand  why  the  patient  had  the  dyspeptic 
symptoms  at  the  cessation  of  the  rumination,  and  his 
wish  and  hope  that  "his  habit  mhII  return  as  suddenly 
as  it  left  him,"  justifiable. 

Soon  afterward,  however.  Boas'  published  a  case  of 
rumination  in  which  the  chemical  analysis  of  the 
stomach  contents  showed  the  acidity  to  be  markedly 
diminished.  The  treatment  consisted  in  giving  the 
patient  hydrochloric  acid,  and  the  result  was  a  diminu- 
tion of  the  rumination  and  an  amelioration  of  the 
glandular  function  of  the  stomach.  In  this  way  by 
Boas'  case  Alt's  theory  has  been  refuted.  Shortly 
afterward  Juergensen'  published  two  cases  of  rumina- 
tion, with  an  absence  of  the  free  hydrochloric  acid. 

In  considering  the  figures  of  the  chemical  analysis 
of  the  stomach  contents  of  merycists  I  have  observed, 
I  must  say  that  no  relationship  whatever  can  be  found 
between  the  chemical  condition  of  the  stomach  con- 
tents and  rumination.  In  some  of  the  patients  the 
condition  of  the  stomach  was  perfectly  normal  in 
every  respect;  the  chemical  analysis  showed  the  pres- 
ence of  hydrochloric  acid  in  a  normal  quantity ;  the 
power  of  motion  also  proved  to  be  adequate;  Ewald's 
salol  reaction  appeared  after  one  hour:  in  others  the 
chemical  analysis  of  the  stomach  contents  varied 
greatly  on  different  days.  There  was  found  once 
normal  acidity  (50),  once  rather  subacidity  (4:0),  and 
once  hyperacidity  (100),  whereas  hydrochloric  acid  was 
always  present.     In  some,  again,   there  was  hyper- 

'Boas:  Berl.  klin.  Wochenschr.,  1888,  No.  831. 
^  Juergensen  :  Berl.  klin.  Wochenschr.,  1888,  No.  46. 
28 


434  DISEASES   OF   THE   STOMACH. 

chlorhydria,  while  in  others  achylia  gastrica  prevailed. 
The  conjecture  of  Ewald  is  therefore  confirmed.  This 
author,  in  his  book  on  the  "Diseases  of  the  Stomach," 
says  in  reference  to  rumination:  "I  would  not  be  as- 
tonished, the  conditions  being  the  same,  if  varying 
degrees  of  acidity  were  found  in  the  same  patient,  be- 
cause such  changeable  conditions  are  in  the  nature  of 

many    neuroses."      One    of     my    patients     (K ) 

furnished  the  best  example  of  such  an  occurrence, 
and  from  this  we  can  infer  that  no  connection  exists 
between  rumination  and  the  chemical  condition  of  the 
stomach. 

During  the  last  nine  years  I  have  observed  twenty- 
two  cases  of  rumination.  One  of  the  first  cases,  which 
I  described  in  the  Medical  Record,^  was  as  follows: 

March   26th,   1890:  G.  P ,   physician,   aged  27, 

had  febris  gastrica  in  his  childhood,  and  in  1884 
typhoid  fever.  Since  his  ninth  year  the  patient  has 
been  troubled  with  his  stomach ;  at  that  time,  during 
a  period  of  six  months,  he  usually  vomited  after  par- 
taking of  food,  especially  of  fluid.  Sometimes  the 
patient  had  to  vomit  at  the  beginning  of  the  meal, 
immediately  after  the  soup,  but  could  nevertheless 
continue  to  partake  of  his  meal  directly  afterward. 
Since  then  his  condition  has  become  ameliorated,  and 
instead  of  vomiting  there  appeared  rumination. 

The  rumination  in  this  patient  appears  spontane- 
ously, about  one  hour  after  meals,  and  continues  for 
about  a  quarter  of  an  hour.  The  food  comes  up  in 
small  quantities  (in  the  form  of  boli).  The  taste  is 
not  sour;  in  chewing  the  cud  the  patient  has  a  pleas- 
ant sensation. 

>  Max  Einhorn:  "Rumination  in  Man,"  Medical  Record,  I.  c. 


RUMIXATION.  435 

When  he  partakes  of  liquid  food  only  (as,  for  in- 
stance, beer,  bouillon,  coffee,  milk),  there  is  no  rumi- 
nation. 

In  this  patient  the  rumination  appears  periodically ; 
thus,  for  instance,  he  ruminated  three  months,  and 
then  Tvas  free  from  the  trouble  for  about  a  year. 

Even  during  the  period  of  rumination  the  bowels 
act  regularly ;  the  patient,  however,  often  suffers  from 
belching. 

He  is  able  to  ruminate  at  will  any  time  there  is  food 
in  his  stomach.  The  act  of  rumination  proceeds  even 
then  without  any  effort.  In  order  to  effect  the  rumi- 
nation the  patient  closes  his  glottis  and  exerts  slight 
pressure  over  the  stomach  by  means  of  his  abdominal 
muscles;  the  contents  are  then  ejected  in  small  por- 
tions into  the  mouth.  Patient  is  able  to  do  this  in 
any  posture;  when  he  is  sitting  or  standing,  however, 
it  is  done  with  more  ease  than  in  a  recumbent 
position.  In  the  same  way  the  patient  is  voluntarily 
able  to  belch  and  to  vomit;  the  latter  in  such  a  way 
that  all  the  stomach  contents  are  ejected  at  once.  The 
patient  is  thus  enabled  to  cleanse  his  stomach  easily  ; 
he  does  this  by  drinking  a  large  quantity  of  water  and 
ejecting  it  immediately  after.  He  also  has  the  faculty 
of  stopping  the  vomiting  at  any  moment  he  chooses, 
and  in  this  way  he  can  alternate  vomiting  with  rumi- 
nation.    He  has  diplojDia  and  is  color-blind  in  one  eye. 

The  father  of  the  patient  and  several  of  his  brothers 
and  sisters  are  troubled  with  the  stomach;  the  main 
symptom  of  their  ailment  is  belching;  nobody  in  the 
family,  however,  had  ruminated.  The  patient  is  able 
to  suppress  rumination,  not  feeling  any  pain  in  doing 
so.  He  does  not  know  what  causes  the  periodical 
attacks  of  rumination,  although  he  has  noticed  that 
after  any  excitement  he  is  more  liable  to  have  an 
attack. 


436  DISEASES   OF   THE   STOMACH. 

The  physical  examination  shows  no  abnormal  con- 
ditions whatever.  Patient  is  of  medium  height,  well 
developed,  somewhat  stout.  Tongue  perfectly  clean. 
The  stomach  does  not  seem  to  he  dilated.  Seven 
seconds  after  swallowing  water  a  rattling  sound  ap- 
pears on  auscultation  at  the  xyphoid  process. 

Examinations  of  the  Stomach. — 1.  During  the 
rumination  period,  September  15th,  1888.  One  hour 
after  Ewald's  test  breakfast:  HCl  +;  acidity  =  50; 
erythrodextrin  +;  achroodextrin  -\-.  On  the  same 
day  the  patient  took  1.0  gm.  salol  in  a  gelatin  capsule; 
the  urine  showed  the  salicyluric  acid  reaction  (it  be- 
came dark  red  on  addition  of  a  few  drops  of  liquor 
ferri  sesquichloridi)  after  one  hour. 

2.  During  an  interval  of  freedom  from  rumination, 
March  25th,  1890.  One  hour  after  test  breakfast: 
HCl  + ;  acidity  =  54 ;  erythrodextrin  +  ;  achroodex- 
trin +  .  After  this  examination  the  patient  had  an 
attack  of  rumination  for  three  days,  then  it  ceased. 

Treatment. — Formerly  hydrochloric  acid,  alkalies, 
narcotics,  and  bitters  were  tried  empirically  now  and 
then,  with  apparent  results  for  a  short  time,  and  some- 
times without  any  influence  whatever.  Lately  the 
attempt  has  been  made  to  remedy  the  error — if  any 
— ascertained  after  a  chemical  examination  of  the 
stomach  contents,  and  hydrochloric  acid  or  alkalies 
have  accordingly  been  given,  with  good  results. 

Koerner  tried  giving  small  pieces  of  ice  immediately 
after  meals,  and  warmly  recommends  this  method. 
Washing  out  of  the  stomach  has  been  practised  by 
Johannessen,  and  gavage  (feeding  through  the 
stomach  tube)  during  fourteen  days  by  Juergensen. 
but  with  only  temporary  relief.     All  these  remedies 


NERVOUS   VOMITING.  437 

sometimes  effect  a  temporary  amelioration  ;  a  perma- 
nent cure,  however,  has  never  been  achieved  by  thera- 
peutic means.  As  an  exception  to  this  rule  we  might 
perhaps  consider  the  moral  treatment — i.e.,  the  pa- 
tient determines  not  to  ruminate  and,  as  soon  as  a  de- 
sire to  ruminate  appears,  endeavors  to  suppress  it. 
Ponsgen'  mentions  two  cases  of  merycism  perfectly 
cured  by  this  method. 

This  moral  treatment  can  of  course  be  applied  more 
easily  in  cases  in  which  the  rumination  can  be  sup- 
pressed by  the  will  power  of  the  patient,  although  even 
in  those  in  which  the  rumination  is  wholly  indepen- 
dent of  the  will  it  can  also  be  effected. 

In  treating  Dr.  G.  P.,  I  made  use  of  this  method; 
he  was  instructed,  as  soon  as  he  felt  any  inclination 
to  ruminate,  to  try  with  all  his  power  to  suppress  it. 
The  patient  has  carried  out  this  rule  quite  conscien- 
tiously, and  the  merycism  has  since  that  time  occurred 
only  occasionally.  In  the  treatment  of  several  other 
cases  I  have  applied  the  same  method  with  the  best 
result. 

Nervous  Vomiting  {Vomitus  Nervosus). 

The  process  of  vomiting  serves  to  empty  the  stomach 
of  its  contents  by  the  shortest  way,  that  is,  through 
the  oesophagus  and  mouth.  The  mechanism  of  this 
action  is  very  complicated  and  a  large  number  of 
striated  and  non-striated  muscles  participate  in  it. 
At  first  the  abdominal  muscles  and  the  diaphragm 
contract   and  compress  the   abdominal  cavity;    then 

'  Ponsgen  •  "  Die  motorischen  Verrichtungen  des  menschlichen 
Magens, "  Strassburg,  1882,  p.  127. 


438  DISEASES   OF   THE   STOMACH. 

the  stomach  contracts  and  the  pylorus  closes  firmly. 
At  the  same  time  the  longitudinal  fibres  of  the  lower 
end  of  the  oesophagus  contract  and  open  the  cardia ; 
the  pressure  which  is  exerted  by  the  stomach  upon  its 
contents  throws  them  into  the  open  oesophagus,  which 
becomes  wider  and  shorter  by  the  contraction  of  its 
longitudinal  fibres.  The  epiglottis  turns  upon  the 
larynx  and  closes  up  this  canal,  while  the  soft  palate 
rises  and  covers  the  posterior  nares.  Both  these 
actions  serve  to  prevent  the  contents  from  reaching 
either  the  larynx  or  the  nasal  cavity.  The  only  canal 
which  remains  open  is  the  mouth.  From  the  oesopha- 
gus, by  an  antiperistaltic  contraction  of  the  same,  the 
contents  are  quickly  emptied  through  the  mouth.  It 
is  generally  believed  that  there  exists  a  centre  for  the 
act  of  vomiting  in  the  vagus  nucleus.  It  may  even  be 
that  the  respiratory  centre  and  the  centre  for  vomit- 
ing are  situated  at  one  and  the  same  spot. 

Vomiting  may  be  a  consequence  of  various  patho- 
logical conditions  of  the  stomach,  or  may  be  due  to 
an  abnormal  state  of  the  food.  Nervous  vomiting  is 
characterized  by  the  absence  of  either  of  the  two  con- 
ditions mentioned. 

The  vomiting  may  be  due  to  some  spinal  or  cerebral 
irritation,  or  may  originate  reflexly  from  abnormal 
conditions  in  other  organs  (pharynx,  oesophagus, 
larynx,  palate,  kidneys,  liver,  peritoneum,  genital 
organs,  etc.),  or  it  may  be  due  to  neurasthenia  or 
hysteria.  Among  these  different  kinds  of  nervous 
vomiting  juvenile  vomiting  and  the  periodic  vomiting 
of  Leyden'  deserve  special  consideration. 

'  E.  Leyden  :  I.  c. 


NERVOUS   VOMITING.  439 

Diagnosis. — The  diagnosis  of  nervous  vomiting  has 
a  twofold  object  in  view  :  (1)  To  recognize  the  nervous 
character  of  the  condition,  and  (2)  to  reveal,  if  pos- 
sible, its  cause.  Stiller'  gives  the  following  points 
as  characteristic  of  nervous  vomiting :  It  occurs  easily, 
without  anv  effort  and  without  any  preparatory  stage. 
It  is,  as  a  rule,  independent  of  the  quality  and  quan- 
tity of  the  ingested  food.  Other  points  he  mentions 
are:  The  capriciousness  with  which  certain  kinds  of 
food  (sometimes  very  easily  digestible)  are  ejected, 
while  other  indigestible  substances  are  w^ell  borne; 
the  faculty  which  sometimes  exists  in  selecting  only 
one  certain  substance  from  the  various  food -stuffs 
present  in  the  stomach  for  the  vomiting ;  the  careless- 
ness with  which  the  patients  bear  this  condition  for  a 
long  time;  the  very  slight  or  hardly  marked  degree  of 
inanition,  notwithstanding  the  long  duration  of  the 
ailment.  The  vomiting  is  not  always  dependent  upon 
the  meals,  but  may  occur  occasionally  in  the  fasting- 
condition.  There  exist  other  neuropathic  symptoms, 
which  may  be  associated  with  the  vomiting  or  alter- 
nate with  it — the  influence  which  psychical  conditions 
exert  upon  the  vomiting.  To  these  points  Boas'  adds 
another  one,  namely,  normal  secretory  and  motor 
functions  of  the  stomach.  I  agree,  however,  with 
Bouveret  that,  while  this  ma}^  be  present  in  some  cases, 
there  certainly  occur  cases  of  nervous  vomiting  in 
which  the  gastric  secretory  function  is  greatly  dimin- 
ished or  even  absent. 

Juvenile  Vomiting. — This  condition  occurs  in  young 

1  stiller:  "Die  nervosen  Magenkrankheiten,"  Stuttgart,  1884. 
2 Boas:  I.  c,  p.  238. 


440  DISEASES   OF   THE   STOMACH. 

persons  attending  school,  especially  if  they  are  over- 
worked. Symptoms  of  cardialgia  and  vomiting  de- 
velop, the  latter  appearing  either  once  or  twice  every 
day,  or  presenting  a  rather  periodic  character.  Oc- 
casionally there  is  a  train  of  the  following  symptoms 
associated  with  this  vomiting:  severe  headache, 
marked  pallor,  very  slow  pulse,  and  dilated  pupils. 
The  diagnosis  of  this  form  of  vomiting  is  easily  made 
by  the  symptoms  just  mentioned.  The  best  treatment 
is  the  temporary  removal  of  the  patient  from  school, 
and  a  good,  strengthening  diet. 

Periodic  Vomiting  (Leyden). — Leyden  first  de- 
scribed periodic  vomiting,  which  is  characterized  by  the 
following  points:  1.  It  appears  in  apparently  healthy 
individuals;  2.  The  paroxysms  occur  periodically 
after  intervals  of  equally  long  duration  ;  3.  When  the 
attack  is  over,  the  patient  is  perfectly  well  and  no 
gastric  symptoms  persist. 

The  attack  is  very  similar  to  that  of  acute  suc- 
corrhcea  gastrica  continua,  and  may  be  described  as 
follows:  In  the  midst  of  perfect  health  the  jDatient 
experiences  for  a  short  time  uneasy  sensations  (slight 
headache,  nausea,  slight  chilly  feeling)  which  are 
followed  by  vomiting.  At  first  the  entire  gastric  con- 
tents are  ejected ;  later  the  vomited  matter  consists  of 
mucus,  alone  or  with  admixture  of  either  bile  or 
shreds  of  blood.  The  latter  is  more  frequently  found 
if  violent  retching  has  preceded  the  act  of  vomiting. 
Frequently,  although  not  always,  there  exist  an  in- 
tense pain  in  the  epigastric  region  and  a  sensation  of 
utter  prostration.  The  abdomen  is,  as  a  rule,  sunken 
and  the  extremities  are  cold.     At  this  time  no  food 


NERVOUS   VOMITING.  441 

whatever  is  borne  by  the  stomach ;  even  a  drink  of 
water  is  very  soon  ejected.  This  condition  of  utter 
irritability  of  the  stomach  and  persistent  vomiting 
may  last  from  one  to  ten  days,  when  suddenly  the 
disturbances  disappear,  the  nausea  subsides,  and  a 
feeling  of  hunger  returns,  which  can  be  satisfied  with 
impunity.  All  kinds  of  food  are  now  well  borne  by 
the  stomach,  which  but  an  hour  before  could  not  re- 
tain the  lightest  food. 

The  periodic  vomiting  of  Leyden  is  a  rare  affection, 
and  it  does  not  seem  to  me  that  the  condition  of  the 
gastric  secretion  plays  an  important  part  in  its  causa- 
tion. While  most  of  the  cases  mentioned  in  literature 
seem  to  have  been  associated  with  a  normal  condition 
of  the  gastric  juice,  I  have  observed  a  case  of  periodic 
vomiting  in  a  patient  who  was  affected  with  achylia 
gastrica.  This  patient  (J.  S.),  thirty-seven  years  old, 
had  been  troubled  for  the  last  six  years  with  periodic 
attacks  of  vomiting,  which  appeared  once  in  either  six 
or  three  months  and  lasted  from  four  to  five  days. 
During  the  intervals  the  patient  could  partake  of  all 
kinds  of  food  without  much  inconvenience.  The 
only  complaints  referred  to  were  frequent  belching 
and  constipation.  During  the  attacks  the  patient 
could  not  ingest  anything  for  the  entire  five  days  and 
as  a  rule  presented  the  most  alarming  symptoms.  I 
examined  him  frequently  during  the  intervals  and 
also  during  the  attacks  and  never  found  any  traces  of 
gastric  juice  in  the  contents. 

The  treatment  consists  in  absolute  rest,  in  the  ad- 
ministration of  ice  pills,  and  in  the  use  of  morphine 
(subcutaneous  injection)  or  of  opium  in  the  form  of 


442  DISEASES   OF   THE   STOMACH. 

suppositories.  During  the  intervals  between  the 
attacks  a  sojourn  in  the  country  and  hydropathic  pro- 
cedures may  prove  of  value. 

Reflex  Vomiting. — jS^ervous  vomiting  frequently 
occurs  as  a  result  of  derangements  of  various  other 
organs.  Thus  abnormal  conditions  of  the  pharynx, 
an  elongated  uvula,  disorders  of  the  genito-urinary 
organs  may  be  associated  with  vomiting.  The  vomit- 
ing of  pregnancy  must  also  be  considered  as  belonging 
to  this  group.  Floating  kidney,  hydronephrosis,  he- 
patoptosis  may  likewise  be  the  cause  of  vomiting. 

The  treatment  of  this  class  of  cases  will  have  to  be 
directed  toward  the  seat  of  the  original  trouble.  An 
elongated  uvula  must  be  amputated,  and  ptosis  of 
the  different  abdominal  organs  must  be  remedied  by 
keeping  them  in  place  by  means  of  a  suitable  bandage. 
All  the  genito-urinary  disorders  should  be  treated  as 
such.  The  vomiting  of  pregnancy  must  be  considered 
as  a  physiological  phenomenon  as  long  as  it  occurs 
during  the  first  months  of  pregnancy  and  appears 
only  once  or  twice  a  day,  not  interfering  much  with 
the  general  nutrition.  In  this  case  it  is  hardly  neces- 
sary to  use  any  therapeutic  means.  If,  however,  the 
vomiting  appears  more  frequently  and  obstinately,  so 
that  the  patient  begins  to  lose  in  weight,  then  we 
have  the  following  remedies  at  our  disposal :  Bromide 
of  sodium,  1  gm.  (gr.  xv.),  to  be  taken  twice  daily; 
cerium  oxalate,  2  dgm.  (gr.  iii.)  three  times  daily. 

I^  Menthol, 1.0 

Aq.  dest.,       .                 100.0 

Spir.  frument.  rectif. ,          .         .         .         .  50.0 

Syr.  zingib.,           .                 ....  30.0 

D.    S.  One  tablespoonful  four  times  daily. 


NERVOUS   VOMITING.  443 

Other  remedies,  such  as  cocaine,  codeine,  belladonna, 
or  chloral  hydrate,  may  occasionally  be  useful.  If 
medicinal  treatment  fails,  then  a  change  of  surround- 
ings, as  a  sojourn  in  the  country,  may  be  tried.  If 
all  these  means  prove  useless  and  the  vomiting  con- 
tinues undiminished,  so  that  the  life  of  the  patient  is 
in  danger,  then  as  ultimuiii  refugium,  artificial  abor- 
tion has  to  be  resorted  to. 

Idiopathic  Nervous  Vomiting. — Besides  the  above- 
named  two  groups  of  vomiting,  namely,  the  juvenile 
and  the  periodic,  which  appear  without  any  apparent 
cause,  there  exist  cases  of  vomiting  in  adults  which  do 
not  show  any  periodicity.  The  vomiting  occurs,  as 
a  rule,  after  meals.  Usually  only  a  portion  of  the 
meal  is  ejected;  occasionally,  however,  the  wholemeal 
may  be  vomited.  The  vomiting  may  exist  for  months 
and  sometimes  even  for  years  without  remission.  The 
nutrition,  as  a  rule,  in  these  instances  is  not  disturbed. 
Neurasthenic  and  hysterical  individuals  form  the 
greater  contingent  of  sufferers  from  this  form  of  vom- 
iting. Sometimes,  however,  persons  with  an  appar- 
ently normal  condition  of  their  nervous  functions  may 
be  affected  with  this  trouble,  w^hich  is  by  far  more 
frequent  in  women  than  in  men. 

The  treatment  consists  in  regulating  the  mode  of 
life  of  the  patient  and  in  advising  him  to  suppress 
vomiting  whenever  possible.  In  neurasthenic  and 
hysterical  patients  the  treatment  must  be  directed 
against  the  original  trouble;  in  others  change  of 
climate  may  be  tried.  Of  medicines  the  bromides  play 
a  great  part.  Arsenic  and  iron  are  useful  in  many 
instances.      In    severe    cases    of    vomiting,     feeding 


44J:  DISEASES   OF   THE   STOMACH. 

through  the  tube  for  a  period  of  two  weeks  may  be 
resorted  to.  During  this  time  no  food  is  to  be  taken 
in  any  other  way.  When  this  period  is  over,  then 
small  quantities  of  food  are  administered  per  os,  be- 
sides continuing  the  gavage  (feeding  through  the 
tube).  If  the  food  which  is  taken  by  tlie  mouth  is  no 
longer  vomited,  then  after  a  while  gavage  may  be 
discontinued  and  the  feeding  done  in  the  natural  way. 
Intragastric  faradization  may  also  prove  useful.  Sev- 
eral cases  have  come  under  my  observation  in  which 
nervous  vomiting,  after  having  lasted  for  many  years 
and  resisted  the  most  diverse  modes  of  treatment, 
has  been  perfectly  cured  by  the  faradic  current. 

Pneumatosis. 

Under  the  name  gastric  pneumatosis  are  classified  a 
group  of  cases  in  which  the  stomach  is  distended  with 
gas  (air),  giving  rise  to  a  sensation  of  marked  tension 
and  frequently  also  to  shortness  of  breath  (asthma 
dyspepticum,  Henoch).  It  is  generally  believed  that 
a  spasmodic  contraction  of  both  the  cardia  and  pylorus 
is  partly  the  cause  of  this  condition.  This  affection 
may  appear  periodically  or  exist  constantly.  It  is 
often  found  associated  with  other  symptoms  of  neu- 
rasthenia or  hysteria ;  occasionally,  however,  it  is  met 
with  alone.  In  typical  cases  of  pneumatosis  the 
epigastric  and  gastric  regions  are  found  greatly  pro- 
tuberant, sometimes  the  uj^per  jDart  of  the  abdomen 
looks  like  a  balloon.  On  percussion  this  area  gives  a 
highly  tympanitic  sound.  The  patients  experience  a 
sensation  of  distention  and  marked  want  of  air;  some- 
times a   feeling  of  utmost  anxiety    is   also    present. 


HYPANAKINESIS   VENTRICULI.  445 

Belching,  as  a  rule,  cannot  be  produced  by  these 
patients. 

In  making  the  diagnosis  of  this  condition,  it  will  be 
necessary  to  exclude  organic  affections  of  the  stomach 
which  may  give  rise  to  similar  symptoms.  In  the  lat- 
ter, however,  the  gas  accumulated  in  the  stomach  will 
have  a  foul  odor. 

The  treatment  consists  in  a  general  tonic  regimen  of 
the  nervous  system  and  in  the  administration  of  the 
bromide  salts.  An  acute  attack  of  pneumatosis  can 
be  checked  in  the  quickest  and  easiest  way  by  the  in- 
troduction of  a  tube  into  the  stomach,  so  that  the 
imprisoned  air  can  find  an  exit.  The  symptoms  of 
tension  then  disappear  at  once.  This  procedure  must 
be  repeated  whenever  a  considerable  quantity  of  gas 
has  accumulated  in  the  stomach  and  given  rise  to  the 
characteristic  symptoms.  If  a  tube  is  not  at  hand,  or 
its  introduction  be  inadvisable,  the  attack  may  be 
relieved  by  a  subcutaneous  injection  of  morphine 
(Ewald).  The  extract  of  Calabar  bean  may  also  be 
found  very  useful, 

Hypanakinesis  Ventriculi. 

I  have  applied  the  term  hypanakinesis  to  a  condi- 
tion in  which  the  mechanical  function  of  the  stomach 
is  greatly  reduced.  If  tested  with  the  gastrograph 
there  are  found  only  three  or  four  "breaks"  and 
"makes"  of  the  current  marked  within  three  minutes. 
Sometimes  no  current  changes  whatever  are  observed 
within  the  same  time.  I  have  noticed  this  condition 
several  times  in  gastric  ulcer,  but  twice  also  in  persons 
in  which  the  diagnosis  of  gastric  ulcer  could  be  ex- 


4-46  DISEASES   OF   THE   STOMACH. 

eluded.  One  of  the  latter  usually  complained  that  he 
experienced  the  most  disagreeable  sensation  soon  after 
meals  when  resting  quietly.  He  felt  relieved  only 
when  walking  about  for  three-quarters  of  an  hour  or 
an  hour  after  each  meal.  It  may  be  that  the  exercise 
which  the  patient  instinctively  resorted  to  served  to 
supplement  the  mechanical  work  of  the  stomach  that 
was  lacking. 

Hyperanakinesis  Ventriculi. 

In  contrast  to  the  above,  hyperanakinesis  ventriculi 
denotes  a  condition  of  too  strong  mechanical  action  of 
the  stomach.  The  gastrograph  shows  forty  to  eighty 
"  breaks"  and  "  makes"  of  the  current  within  three 
minutes.  This  symptom  is  frequently  foand  to  be 
present  in  cases  of  obstruction  at  the  pylorus,  but  may 
occur  in  other  conditions.  In  several  of  my  cases 
this  symptom  was  associated  with  hyperchlorhydria. 

Peristaltic  Restlessness  of  the  Stomach  (Kussmaul '), 
Tormina  Ventriculi  Nervosa. 

Under  this  heading  are  grouped  those  cases  in  which 
there  is  not  only  an  increased  motor  (mechanical) 
activity  of  the  stomach,  but  in  which  the  peristaltic 
movements  are  distinctly  visible. 

In  this  condition  the  peristaltic  action  of  the  stom- 
ach is  remarkably  active.  High  waves  can  be  seen 
moving  along  the  stomach  from  left  to  right.  The 
time  required  for  one  wave  to  pass  from  the  extreme 
left  to  the  pylorus  is  about  one  minute.     This  visible 

'Kussmaul:  "Die  peristaltische  Unruhe  des  Magens. "  Volk- 
mann's  Samml.  kliu.  Vortrage,  No.  181,  1880. 


PERISTALTIC   RESTLESSNESS   OF   THE   STOMACH.       44? 

peristaltic  action  of  the  stomach  is  more  pronounced 
when  it  is  filled  with  food.  In  some  instances  the 
exaggerated  peristalsis  is  felt  by  the  patient  as  a 
slightly  painful  contraction.  In  other  instances  it  is 
not  perceptible  to  the  patient.  Peristaltic  restlessness 
of  the  stomach  is  usually  found  in  dilated  stomachs 
with  obstruction  of  the  pylorus.  Here  it  signifies  the 
effort  which  the  stomach  makes  to  overcome  the  undue 
resistance  which  the  contents  find  in  passing  through 
the  stenosed  pylorus.  In  rare  instances  peristaltic 
restlessness  of  the  stomach  may  occur  alone  without 
any  obstruction  of  the  pylorus,  in  that  case  being  a 
pure  neurosis.  Kussmaul  has  described  two  such 
cases  of  nervous  origin.  I  have  had  the  opportunity 
of  observing  eight  cases  of  peristaltic  restlessness  of 
the  stomach  in  stenosis  of  the  pylorus  (seven  cases  of 
cancer  and  one  case  of  benignant  stenosis)  and  only 
one  case  of  nervous  origin.  The  latter  was  in  a  man, 
forty-two  years  old,  who  presented  distinct  symptoms 
of  neurasthenia  and  complained  of  a  moving  cramp- 
like sensation,  which  usually  appeared  soon  after 
meals  in  the  gastric  region  and  lasted  for  half  an  hour 
or  longer.  On  inspecting  his  abdomen  half  an  hour 
after  a  light  meal,  small  "mountainous  waves"  could 
be  seen  moving  from  left  to  right  over  the  gastric 
region.  In  this  case  the  greater  curvature  of  the 
stomach  extended  to  one  finger's  breadth  above  the 
navel  (gastrodiaphany)  and  the  stomach  was  usually 
found  empty  one  and  a  half  hours  after  a  test  break- 
fast. 

The  treatment  of  this  affection,  if  associated  with 
pyloric  obstruction,  must  be  directed  against  the  latter 


448  DISEASES   OP   THE   STOMACH. 

primary  trouble.  In  cases  of  neurotic  origin,  our 
therapeutic  measures  will  have  to  be  directed  against 
the  nervous  system.  Massage,  hydrotherapy,  elec- 
tricity {percutaneous  or  intragastric  faradization), 
change  of  climate  and  surroundings  will  frequently 
prove  useful.  Larger  doses  of  potassium  bromide  and 
codeine,  either  alone  or  with  belladonna,  are  often 
beneficial. 

Antiperistaltic  Restlessness  of  the  Stomach. 

Glax,'  Schiitz,"  and  Cahn  ^  have  described  cases  in 
which  the  waves  over  the  stomach  moved  from  right 
to  left,  and  they  therefore  designated  this  condition 
as  "antiperistaltic  restlessness  of  the  stomach." 
Glax's  case  was  of  neurotic  origin.  In  making  the 
diagnosis  of  peristaltic  or  antiperistaltic  restlessness  of 
the  stomach  it  is  of  the  greatest  importance  to  deter- 
mine that  the  visible  waves  originate  within  the  stom- 
ach and  not  in  the  intestines.  Peristaltic  and  anti- 
peristaltic movements  of  the  small  intestines  are 
frequently  observed  and  can  easily  be  distinguished 
from  motions  of  the  stomach  by  the  forms  presented 
by  the  waves.  If  they  originate  in  the  small  intes- 
tines, they  are  of  small  calibre  (sausage-like)  and  are 
seen  moving  in  different  directions  and  over  different 
regions,  while  the  waves  produced  in  the  stomach  are 
nearly  always  quite  large  (hand-size)  and  always 
move,  if  peristaltic,  from  left  to  right,  if  antiperi- 
staltic from  right  to  left,  in  the  upper  part  of  the 
abdominal  cavity. 

'Glax:  Pest,  med.-chirurg.  Presse,  1884. 
'Schiitz:  Pragermed.  Wochenschr.,  1882,  No.  11. 
3Cahn:  Deutsch.  Arcli.  f.  klin.  Med.,  1884,  p.  402. 


IXCOXTINENTIA   PYLORI.  449 

Incontinentia  Pylori  {Incontinence  of  the  Pylorus). 

Incontinence  of  the  pylorus  was  first  described  by 
L.  de  Sere'  and  later  by  Ebstein/  The  pylorus  may 
be  incompetent,  first,  when  unyielding  neoplasms  in- 
volve this  portion  of  the  stomach ;  secondly,  when  the 
pyloric  sphincter  is  in  an  atonic  condition,  i.e.,  when 
the  pylorus  is  apparently  always  open  by  reason  of 
some  nervous  derangement.  Ebstein  diagnoses  an  in- 
continence of  the  pylorus  if  on  inflating  the  stomach 
with  air  the  latter  rapidly  passes  into  the  intestines, 
so  that  it  becomes  impossible  to  fill  the  organ  with 
gas.  Instead  of  the  stomach,  the  small  intestines 
then  become  filled  with  air  and  give  tympanitic  sounds 
on  iDercussion.  Ewald  justly  doubts  the  accuracy  of 
this  diagnostic  means.  He  has,  indeed,  never  ob- 
served this  symptom.  In  all  the  cases  in  which  he 
had  distended  the  stomach  to  its  utmost  extent  with 
air,  he  could  never  demonstrate  that  the  air  passed 
into  the  intestines.  Whenever  the  tension  became 
too  great,  the  air  always  escaped  upward  through  the 
cardia  with  eructation.  My  own  experience  coincides 
with  that  of  Ewald.  Incontinence,  or  rather  relaxa- 
tion of  the  pylorus,  is  a  rare  condition,  and  we  are 
able  to  recognize  it,  not  so  much  by  the  fact  that  food 
and  gas  pass  from  the  stomach  into  the  duodenum 
more  rapidly  than  normally,  as  by  the  regurgitation 
of  intestinal  contents  into  the  stomach.  The  presence 
of  the  latter  condition  is  shown  by  the  fact  that  on 

'L.  de  Sere:  "Du  Eelachement  du  Pylore."  Gaz.  des  hop.,  1864 
No.  62. 

^Ebstein:  Deutsch.  Arch.  f.  klin.  Medicin,  Bd.  26,  p.  295. 
29 


450  DISEASES   OF   THE   STOMACH. 

washing  out  the  stomach  in  the  fasting  condition, 
more  or  less  large  quantities  of  intestinal  juice  and 
especially  of  bile  almost  always  appear.  While  the 
occasional  regurgitation  of  intestinal  secretion  into 
the  stomach  may  occur  as  a  consequence  of  irritation 
caused  by  the  tube  when  lavage  is  applied,  still  the 
quantity  of  the  intestinal  juice  is  always  small.  In 
incontinence  of  the  pylorus,  the  quantity  of  regurgi- 
tated intestinal  juice  and  bile  is  considerable  and  al- 
ways present  in  the  fasting  condition  at  each  washing 
of  the  stomach,  and  sometimes  also  if  the  contents  of 
the  organ  are  withdrawn  one  hour  after  the  test  break- 
fast or  three  to  four  hours  after  a  test  dinner. 
Whether  the  condition  in  which  the  stomach  becomes 
empty  more  rapidly  than  normally  is  to  be  referred 
to  a  relaxation  of  the  pylorus,  or  to  an  increased 
motor  function  (hyperprochoresis)  of  the  organ,  is  still 
undecided.  In  most  instances,  however,  it  seems  to 
me  that  the  latter  factor  is  the  more  probable.  I  have 
observed  two  cases  of  relaxation  of  the  pylorus,  and 
both  have  been  treated  by  intragastric  faradization 
with  good  results.  Occasionally  relaxation  of  the  py- 
lorus is  combined  with  relaxation  of  the  cardia,  as  the 
following  case  well  illustrates: 

Miss  Emma  M ,  24  years  of  age,  suffering  for 

three  years  from  loss  of  appetite,  eructation,  consti- 
pation, and  poor  sleep;  there  was  no  vomiting  but 
belching  of  acid  fluid  after  meals.  One  of  the  worst 
complaints  of  the  patient  was  of  this  highly  annoying 
ructus,  which  never  left  her,  and  in  consequence 
of  which  she  was  hampered  in  her  occupation  and 
frequently  kept  away  from  society. 


PYLOEOSPASMUS.  451 

Present  Condition. — Tongue  thickly  coated  ;  splash- 
ing sound  from  the  stomach  to  a  point  two  fingers' 
breadth  below  the  navel :  the  right  kidney  is  clearly 
palpable  and  easily  moved.  Examination  of  the  stom- 
ach in  the  fasting  condition  by  means  of  a  tube  shows 
that  there  is  bile  mixed  with  gastric  juice  in  the 
stomach ;  also  after  the  test  breakfast  the  contents  of 
the  stomach  were  usually  found  mixed  with  bile,  as 
will  be  seen  from  the  following  memorandum : 

One  hour  after  the  test  breakfast :  HCl  +  ;  acidity 
=  Q^ ;  admixture  of  bile. 

When  fasting,  the  stomach  contains  70  c.c.  of  an  in- 
tensely yellow-colored  fluid  (bile  present) ;  HCl  +. 

The  treatment  consisted  in  direct  gastro-faradiza- 
tion  and  once  in  a  while  washing  of  the  stomach. 
During  the  month  of  April  the  faradization  was  ap- 
plied every  other  day,  and  the  lavage  of  the  stomach 
once  a  week  in  the  fasting  condition.  The  patient 
felt  better  after  a  few  days'  treatment;  the  eructation 
disappeared  almost  entirely,  and  she  could  eat  with 
good  appetite,  having  no  distress  afterward. 

Subsequently  the  faradization  was  applied  once  a 
week  and  then  discontinued.  The  patient  gained  sev- 
eral pounds  during  the  treatment,  and  has  been  pretty 
free  from  complaints  since  that  time. 

Pylorospasmus. 

A  spasmodic  contraction  of  the  pylorus  without  or- 
ganic disease  has  been  described  by  Bentejac'  He 
reports  the  following  case : 

A  man,  59  years  old,  swallowed  a  glassful  of  kero- 
sene by  mistake.  After  this  accident  he  was  troubled 
with  intense  pains  in  his  epigastric  region,  but  never 

1  Bentejac  :  These  de  Paris,  1888. 


452  DISEASES   OF   THE   STOMACH. 

vomited  blood  nor  did  he  pass  blood  with  his  move- 
ments. At  the  end  of  eight  months  there  was  inces- 
sant vomiting  and  the  dilated  stomach  extended  below 
the  navel.  Stenosis  of  the  pylorus  was  diagnosed,  and 
Richelot  performed  an  exploratory  laparotomy,  but 
found  the  pylorus  perfectly  smooth  and  normal.  The 
result  of  the  examination  during  the  operation  proved 
that  the  pylorus  was  only  spasmodically  contracted. 
The  operation,  however,  had  the  result  that  the  pa- 
tient ceased  to  suffer  from  vomiting,  which  must  be 
ascribed  merely  to  the  suggestive  effect  of  the  pro- 
cedure. 

Pylorospasmus  is  frequently  found  in  association 
with  ulcer,  either  of  the  pylorus  or  of  its  immediate 
neighborhood,  and  must  then  be  considered  as  a  reflex 
neurosis.  The  symptoms  produced  resemble  in  most 
instances  a  real  stenosis  of  the  pylorus;  and  if  several 
attempts  to  improve  the  condition  have  totally  failed, 
then  surgical  interference  must  be  resorted  to.  Bou- 
veret '  states  that  pylorospasmus  frequently  occurs  in 
cases  of  hyperchlorhydria  and  especially  of  hyperse- 
cretion. The  fact  that  in  these  cases  the  pyloric  re- 
gion is  sometimes  found  to  be  painful  and  very  tender 
on  pressure,  Bouveret  refers  to  an  undue  spasmodic 
contraction  of  the  pylorus.  I  must  say  that  this 
symptom  alone  is  not  sufiScient  to  warrant  the  as- 
sumption of  pylorospasmus.  The  pains  which  are 
felt  more  to  the  right  side  may  be  caused  by  the  un- 
due irritation  which  too  acid  chyme  exerts  during  its 
passage  through  the  pylorus. 

'  Bouveret :  I.  c. 


ATONY   OF   THE   STOMACH.  453 

Atony  of  the  Stomach. 

Synonyms.— Gastvic  insufficiency  (Eosenbach') ;  my- 
asthenia ventriculi  (Boas). 

Atony  of  the  stomach  designates  a  condition  in 
which  the  muscular  action  of  the  organ  is  retarded 
and  weakened.  It  occurs  as  a  frequent  complication 
of  many  digestive  disorders,  and  also  of  other  diseases 
which  greatly  weaken  the  constitution.  Thus  we  find 
it  accomiDanymg  chronic  gastric  catarrh,  hyperchlor- 
hydria,  neurasthenia  gastrica,  tuberculosis  of  the 
lungs,  grave  heart  affections,  and  the  like.  Some- 
times, however,  this  condition  exists  as  a  primary 
neurosis. 

Symptomatology. — If  atony  occurs  as  a  complica- 
tion to  another  affection,  the  symptoms  of  atony  will 
be  overshadowed  by  those  of  the  principal  trouble. 
If  it  exists  alone,  the  following  characteristics  are  fre- 
quently present.  An  uncomfortable  feeling  of  fulness 
appears  after  meals ;  often  there  is  eructation  of  gas ; 
the  appetite  is  diminished ;  headaches  and  constipa- 
tion are  frequently  present. 

Diagnosis. — ^The  diagnosis  is  based  upon  the  pres- 
ence of  the  above-described  symptoms  and  the  detec- 
tion of  the  following  points  on  examination  : 

1.  The  splashing  sound  is  easil}^  produced  in  the 
gastric  region,  even  if  the  stomach  contains  only  a 
small  quantity  of  chyme  or  liquid.  As  a  rule,  the 
area  over  which  the  splashing  sound  can  be  produced 
extends  from  the  margin  of  the  ribs  on  the  left  side 
to  the  umbilicus  or  somewhat  below  it. 

'  Rosenbach  :  Volkmann's  Samml.  klin.  Vortrage,  1878,  No.  153. 


454  DISEASES   OF   THE   STOMACH. 

2.  Six  to  seven  hours  after  Leube's  test  dinDer,  the 
washing  out  of  the  stomach  reveals  the  presence  of  a 
more  or  less  considerable  quantity  of  chyme;  while 
the  stomach  is  found  empty  in  the  morning  in  the 
fasting  condition. 

3.  On  filling  the  stomach  with  water,  the  greater 
curvature  will  descend  lower  and  lower  as  water  is 
added.  This  symptom,  however,  which  has  been  de- 
scribed by  Pacanowski '  and  Boas,  is  not  constant  and 
therefore  not  reliable. 

The  prognosis  of  atony  of  the  stomach  is  not  bad, 
as  the  affection  is  quite  amenable  to  treatment. 

Treatment. — A    hygienic    way    of     living    and    a 
strengthening    regime    should    be    advocated.      Too 
much  brain  work  should  be  forbidden,  and  plenty  of 
outdoor  exercise  and  frequent  bodily  ablutions  are  to 
be  enjoined.     Slow  eating  and  thorough  mastication 
of  the  food  are  of  the  greatest  importance.    The  quan- 
tity of  fluids  should  be  restricted.     Not  more  than 
from  one  to  one  and  one-half  quarts  of  liquid,  includ- 
ing tea,  coffee,  milk,  and  soup,  should  be  given  daily. 
As  a  rule  it  is  best  to  have  the  patient  take  five  meals 
a  day.     The  diet  should  consist  of  light  solid  food 
(bread  and  butter,  eggs,  mashed  and  baked  potatoes, 
farina,   hominy,   soup  with  vermicelli),  tender  meat 
(tenderloin  steak,    lamb   chops,    roast    beef,    chicken, 
squab),  fish,  oysters;  spinach,  asparagus,   green  peas, 
carrots;  tea,   coffee,   or  cacao  (with  sugar  and   milk) 
in  small  quantities;  a  small  quantity  of  beer  or  ale. 
Of    medicaments   strychnine   ranks   highest.     I   fre- 
quently give  tincture  nux  vomica  and  fluid  extract  of 

'  Pacauowski :  Deiitsch.  Arch,  f .  klin.  Medicin,  Bd.  40. 


SECRETORY  NEUROSES.  455 

eondurango  equal  parts,  twenty  drops  three  times 
daily.  The  administration  of  ferratin  ^  gm.  three 
times  daily  may  also  frequently  be  found  useful. 

Electricity,  especially  intragastric  faradization, 
seems  to  me  to  be  of  the  greatest  value,  in  order  to 
strengthen  the  muscular  apparatus  of  the  stomach. 
With  regard  to  lavage,  I  concur  with  Boas  that  its 
use  is  not  indicated  in  this  affection. 

The  constipation,  which  is  so  frequently  present,  is 
best  treated  by  having  the  patient  partake  of  plenty 
of  green  vegetables,  brown  and  Graham  bread,  and 
plenty  of  fruit ;  he  should  be  instructed  to  go  to  the 
closet  in  the  morning  always  at  the  same  time.  If 
these  means,  however,  do  not  suffice,  then  I  frequently 
order  the  following  pills : 

i^  Podophyllin, 0.3 

Extr.  uuc.  vom., 

Extr.  fab.  calab., .  aa0,5 

Extr.  gentian., 

Pulv.  glycyrrhizge, aa  q.  s. 

M.  efc  ft.  pil.  No.  30.     S.  One  pill  twice  a  day. 

Instead  of  this  pill  fifteen  to  twenty  drops  of  the 
fluid  extract  of  cascara  sagrada  may  be  given  twice 
daily. 

Secretory  Neuroses. 

The  existence  of  secretory  nerves  governing  the 
glandular  secretion  of  the  stomach  is  generally  ac- 
cepted as  a  fact,  although  they  have  not  as  yet  been 
demonstrated  experimentally  beyond  a  doubt.  Sev- 
eral physiological  facts  speak  in  favor  of  this  view : 
A  piece  of  meat  held  before  the  eyes  of  a  dog  provided 
with  a  gastric  fistula  produces  a  flow  of  gastric  juice. 


456  DISEASES   OF   THE   STOMACH. 

The  same  phenomenon  has  been  observed  by  Eichet ' 
in  the  case  of  a  man  with  a  gastric  fistula.  Fear  and 
great  anxiety  have  a  depressing  effect  on  the  gastric 
secretion.  These  facts  clearly  show  the  influence  of 
nerve  centres  within  the  brain  upon  the  gastric  secre- 
tory function.  There  must,  however,  undoubtedly 
exist  some  nerve  mechanism  within  the  stomach  it- 
self which  regulates  the  secretion ;  for  after  section  of 
the  vagus  and  sympathetic  nerves  supplying  the  stom- 
ach, the  latter  organ  wall  continue  to  produce  its  ordi- 
nary secretion  after  the  aiDplication  of  an  irritant. 
As  in  the  neuroses  previously  considered,  conditions  of 
increased  and  decreased  functions  exist  also  in  these 
cases. 

After  having  described  the  functional  disorders  of 
secretion  under  special  chapters  (Hypersecretion  and 
Achylia  Gastrica),  we  need  say  here  only  that  in  most 
instances  these  affections  are  of  nervous  origin,  either 
prctopathic  or  of  a  reflex  nature.  This  latter  theory 
has  been  especially  advocated  by  Charles  G.  Stock- 
ton,* of  Buffalo. 

Frequently,   however,   disorders   of    secretion   may 
secondarily  accompany  primary  neuroses;  thus  tabes 
dorsalis  and  other  spinal  lesions  are  frequently  associ 
ated   with    hyperchlorhydria  and   also  with   periodic 
gastrosuccorrhoea. 

Neurasthenia  and  hysteria  may  be  complicated  with 
either  hyperchlorhydria  or  hypochlorhydria  or  achylia. 
The   symptoms   which    these    secretory   disturbances 

'  Ch .  Richet :  "  Du  Sue  gastrique  chez  1 '  Homme  et  les  Animaux, " 
Paris,  1878. 

■^  Charles  G.  Stockton  :  Medical  Record,  1894. 


NERVOUS   DYSPEPSIA.  457 

evoke  are  the  same  as  if  they  were  the  primary  affec- 
tioDs. 

Hypochlorhydria  of  nervous  origin  is  sometimes 
met  with  without  the  association  of  other  nervous 
symptoms,  and  it  is  then  quite  difficult  to  establish 
the  diagnosis  between  this  affection  and  gastric 
catarrh.  Absence  of  tenderness  on  pressure  in  the 
gastric  region  and  a  perfectly  clean  tongue  point 
rather  to  the  presence  of  a  neurosis.  Sudden  changes 
in  the  condition  of  the  gastric  secretion  speak  likewise 
in  favor  of  a  neurotic  character. 

Nervous  Dyspepsia  "^  (Leube). 

Leube*  originated  the  name  of  nervous  dyspepsia 
(neurasthenia  gastrica  of  Ewald)  to  describe  a  condi- 
tion characterized  by  manifold  subjective  symptoms, 
which  appear  during  the  act  of  digestion,  but  cannot 
be  referred  to  any  abnormal  condition  in  the  organ 
susceptible  of  objective  demonstration.  All  cases  in 
which  dyspeptic  symptoms  existed  and  in  which  after 
a  test  dinner  hydrochloric  acid  was  detected  and  the 
organ  was  found  empty  seven  hours  after  this  meal, 
Leube  diagnosed  as  nervous  dyspepsia.  Later,  w^hen 
attempts  w^ere  made  to  estimate  the  degree  of  acidity 
quantitatively,  all  the  cases  of  hyperchlorhydria  had 
to  be  sepai-ated  from  this  condition.  For  here  the 
subjective  complaints  of  the  patients  could  be  referred 

'  Nervous  dyspepsia  is  in  reality  a  viixed  7ieurosis  in  which  the 
sensory,  motor,  and  secretory  nerve  mechanism,  either  combined 
or  alternately,  may  play  a  part. 

2 Leube:  "Ueber  nervosa  Dyspepsia."  Deutsch.  Arch.  f.  klin. 
Medicin,  Bd.  23,  1879. 


458  DISEASES   OP   THE   STOMACH. 

to  the  abnormal  condition  existing  in  the  undue  secre- 
tion. Nervous  dyspepsia  may  best  be  characterized 
by  the  existence  of  manifold  clinical  symptoms,  with- 
out any  organic  lesion  whatever. 

Etiology. — The  disease  appears  more  frequently  in 
men  than' in  women.  Although  it  may  occur  at  the 
most  diverse  ages,  still  the  years  between  thirty  and 
forty-five  show  the  greatest  frequency.  Many  debili- 
tating conditions  give  rise  to  the  development  of  this 
trouble :  chlorosis,  lung  troubles,  grippe,  malaria ;  ab- 
normal conditions  of  the  genito-urinary  organs,  sexual 
excess,  excessive  use  of  tobacco  and  alcohol  predispose 
to  this  affection.  Organic  troubles  of  the  stomach, 
such  as  ulcer  or  chronic  gastric  catarrh,  may  also  give 
rise  to  this  complication.  It  is  hardly  necessary  to 
say  that  both  neurasthenia  and  hysteria  are  often 
complicated  with  nervous  dyspepsia,  or,  speaking 
more  correctly,  the  nervous  dyspepsia  in  reality  forms 
a  part  of  these  two  conditions. 

Symptomatology. — The  appetite  is  generally  irregu- 
lar and  capricious.  Sometimes  it  is  increased,  more 
frequently,  however,  it  is  lessened.  The  tongue,  as  a 
rule,  is  clean  and  only  occasionally  slightl}^  coated. 
Vevy  soon  after  a  meal  various  symptoms  appear: 
slight  pains  in  the  gastric  region,  frequent  belching, 
sometimes  an  irresistible  desire  to  sleep,  occasionally 
a  feeling  of  burning  in  the  head,  especially  in  the 
forehead.  All  these  disagreeable  sensations  frequently 
last  as  long  as  there  is  food  in  the  stomach.  Some- 
times, when  the  stomach  is  empty,  a  weak  feeling 
and  slight  dizziness  overcome  the  patient,  so  that  there 
is  really  no  time  whatever  during  which  the  patient 


NERVOUS   DYSPEPSIA.  459 

feels  perfectly  well  and  enjoys  the  feeling  of  a  healthy 
person.  This  explains  the  marked  depression  existing 
in  these  patients.  Most  of  them  look  at  everything 
from  the  darkest  point  of  view,  and  any  small  incon- 
venience, which  would  hardly  be  noticed  by  a  healthy 
iDerson,  may  give  them  great  anxiety  and  fear.  At 
first  the  nutrition  of  the  body  appears  to  be  in  good 
condition.  But  sooner  or  later  the  patient  begins  to 
lose  in  weight,  the  sleep  is  also  very  soon  impaired, 
and  all  the  symptoms  are  aggravated. 

Besides  the  gastric  symptoms  there  are  also  mani- 
fold symptoms  which  refer  to  the  intestines.  Sensa- 
tions of  fulness  or  of  tension,  and  sometimes  also  pain, 
are  experienced  in  different  regions  of  the  abdomen. 
Frequently  these  abnormal  sensations  are  caused  by 
an  accumulation  of  gas  in  the  intestinal  tract  and  re- 
lief is  felt  after  the  passing  of  flatus.  The  bowels  are 
almost  always  constipated.  The  movements  some- 
times appear  in  the  form  of  small  balls  and  occasion- 
ally in  the  form  of  a  very  thin  long  cylinder  the  size 
of  a  quill.  The  latter  is  always  the  result  of  the 
spasmodic  form  of  constipation.  Diarrhoea  is  very 
seldom  met  with  in  this  disease. 

Burkhart '  has  described  the  existence  of  certain 
points  in  the  abdomen  which  are  painful  to  pressure, 
and  believes  them  to  be  characteristic  of  this  affec- 
tion. Leven  ^  likewise  attributes  great  importance 
to  the  appearance  of  these  painful  spots,  which  he 
ascribes  to  an  irritation  of  the  solar  plexus.     He  de- 

'  Burkhart :  "  Zur  Patbologie  der  Neurasthenia  gastrica, "  Bonn, 
1882. 

^  Leven:  "  Estomac  et  Cerveau, "  Paris,  1884. 


460  DISEASES   OF   THE    STOMACH. 

scribes  three  such  painful  areas,  one  immediately  be- 
low the  ensiform  process,  the  others  near  the  navel, 
especially  to  the  left  of  it.  Ewald,  Eichter/  and  Bou- 
veret  are  of  the  opinion  that  this  symptom  is  by  no 
means  characteristic  of  nervous  dyspepsia,  as  they 
have  met  with  cases  of  the  affection  in  which  no  such 
painful  points  could  be  found.  The  condition  of  the 
gastric  juice  does  not  present  anything  characteristic 
of  this  affection.  Frequently  the  juice  will  be  found 
normal.  Sometimes  the  degree  of  acidity  will  be  di- 
minished and  occasionally  increased.  In  many  cases 
the  condition  of  the  gastric  juice  will  reveal  mani- 
fold variations  from  time  to  time.  I  agree  with 
Bouveret  that  more  frequently  a  diminished  acidity  is 
met  with  in  this  affection.  If  the  affection  has  lasted 
quite  a  while,  atony  of  the  stomach  is  usually  present. 
In  w^omen  enteroptosis  very  frequently  occurs  as  a 
complication.  In  both  sexes,  but  more  frequently  in 
the  female,  membranous  colitis  may  develop  in  conse- 
quence of  the  high  degree  of  constipation  and  of  the 
irritation  of  the  colon  through  scybala.  Besides  all 
these  symptoms,  which  refer  to  the  digestive  tract, 
manifold  nervous  symptoms  usually  occur:  headache, 
insomnia,  pains  in  the  back,  frequent  emissions,  some- 
times impotence,  vertigo,  palpitations  of  the  heart 
after  slight  exertions  or  after  meals,  feeling  of  ex- 
treme weakness,  loss  of  energy  and  ambition,  etc. 

The  prognosis  of  neurasthenia  gastrica  is  quite  un- 
certain. Cases  of  a  slight  nature  may  sometimes  re- 
sist the  best  kinds  of  treatment  for  a  long  time.  On 
the  other  hand,  cases  of  a  severer  nature  may  readily 

'Richter:  Berl.  klin.  Wochenschr.,  1882. 


NERVOUS   DYSPEPSIA.  461 

yield  to  rational  treatment.  The  duration  of  the  dis- 
ease can  very  seldom  be  foretold,  and  although  life  is 
not  directly  endangered,  still  instances  of  fatal  issue 
even  without  apparent  complications  have  been  re- 
ported in  literature. 

Diagnosis. — The  presence  of  symptoms  of  general 
neurasthenia,  and  especially  of  those  attributable  to 
the  digestive  tract  without  the  existence  of  a  real  or- 
ganic trouble,  will  establish  the  diagnosis.  The  prin- 
cipal characteristic  of  this  affection  is  the  lack  of  pro- 
portion between  the  multiform  complaints  and  the 
results  objectively  found  in  an  examination  of  the 
digestive  organs.  Another  point  of  value  is  the  cir- 
cumstance that  different  kinds  of  food,  even  indiges- 
tible substances,  do  not  seem  to  aggravate  the 
condition,  nor  does  very  light  food  ameliorate  it, 
while  changes  of  climate  or  surroundings  or 
sometimes  pleasant  news  and  the  like,  may  sud- 
denly check  all  the  unpleasant  sensations  for  a  con- 
siderable time. 

Differential  Diagnosis. — Neurasthenia  gastrica  may 
occasionally  be  confounded  with  chronic  gastric  ca- 
tarrh, ulcer  of  the  stomach,  or  cancer,  the  more  so  as 
all  these  organic  affections  of  the  stomach  are  fre- 
quently associated  with  nervous  symptoms.  The  fol- 
lowing points  will  serve  to  differentiate  between  neu- 
rasthenia gastrica  and  the  affections  mentioned:  in 
neurasthenia  gastrica  the  nervous  symptoms  (refer- 
ring to  the  stomach  and  to  other  distant  organs)  play 
the  most  important  part.  While  the  different  com- 
plaints are  connected  more  or  less  with  the  digestive 
tract,  the  quality  and  quantity  of  food  do  not  seem  to 


462  DISEASES   OF   THE   STOMACH. 

be  of  great  importance.  Sudden  changes  in  the  con- 
dition of  the  patient,  who  feels  entirelj'  well  for  a  few 
days  and  then  again  utterly  disabled,  are  character- 
istic of  neurasthenia  gastrica.  Chronic  gastric  ca- 
tarrh will  be  easily  recognized  by  the  constancy  of  the 
symptoms,  which  are  aggravated  by  errors  in  diet,  and 
by  the  condition  of  the  gastric  secretion  (diminished 
acidity,  large  quantity  of  mucus,  etc.).  In  ulcer  of 
the  stomach  we  shall  always  find  some  of  the  charac- 
teristic points  (circumscribed  painful  spot,  vomiting, 
haematemesis  or  melsena,  pains  after  the  ingestion  of 
food,  as  a  rule  very  intense).  As  is  well  known,  how- 
ever, an  ulcer  may  exist  without  any  of  these  char- 
acteristic symptoms,  and  it  therefore  becomes  very 
difficult  to  exclude  its  presence,  the  more  so  as  neuras- 
thenia gastrica  may  complicate  this  affection.  To  es- 
tablish the  differential  diagnosis  between  neurasthenia 
gastrica  and  cancer  of  the  stomach,  it  is  often  neces- 
sary to  have  the  patient  under  observation  for  quite  a 
period  of  time.  Whenever  there  is  a  tumor  or  other 
distinct  symptoms  of  cancer,  it  is  easy  to  recognize 
the  cancerous  affection.  If,  however,  marked  symp- 
toms are  absent  (during  the  first  period  of  the  disease), 
the  differential  diagnosis  is  difficult.  In  cancer  of  the 
stomach  there  will  also  be  some  relation  between  the 
quality  and  quantity  of  the  ingesta,  and  the  existing 
disturbances.  Moreover,  in  cancer  of  the  stomach 
there  is  progressive  aggravation  of  the  trouble,  while 
in  neurasthenia  gastrica  the  condition  may  remain 
stationary  for  a  long  period  of  time. 

Treatment. — In  all  cases  in  which  some  connection 
can  be  found  between  this  affection  and  other  existing 


NERVOUS   DYSPEPSIA.  463 

ailments,  the  treatment  must  be  directed  against  the 
latter.  If  neurasthenia  gastrica  exists  alone,  then 
therapeutic  means  must  he  resorted  to  which  will 
strengthen  the  entire  nervous  system.  Change  of  cli- 
mate, outdoor  life,  entire  relief  from  business  cares, 
are  of  great  importance,  and  sometimes  sufficient  to 
cure  the  patient.  The  diet  should  be  amjjle,  and  it  is 
of  importance  to  impress  upon  the  patient  the  neces- 
sity of  taking  plenty  of  food.  As  to  the  digestibility  of 
different  kinds  of  food  in  this  affection,  the  patient's 
own  judgment  and  experience  are  the  best  guides 
to  follow.  Condiments  should  be  taken  moderately 
and  the  use  of  wine,  tea,  coffee,  and  beer  in  small 
quantities  is  allowable.  In  patients  who  have  greatly 
emaciated,  Weir  Mitchell's  rest  cure  is  often  followed 
by  the  best  results.  The  direct  means  which  serve  to 
strengthen  the  nervous  system  are  the  following:  1. 
Hydrotherapeutic  measures  of  a  mild  nature  (wet  cold 
pack,  lukewarm  sitz  bath).  '±.  Massage  of  the  entire 
body,  to  which  special  massage  of  the  abdomen  may 
be  added.  3.  Electricity;  general  faradization  of 
Beard  and  Eockwell ;  *  the  patient  sits  barefooted  on  a 
large  plate  electrode,  while  the  other  electrode  is 
passed  by  the  physician  over  the  chest,  back,  and  ex- 
tremities— electric  bath.  -i.  Both  sleep  and  rest  should 
be  accorded  to  the  patient  in  a  large  degree.  While 
gymnastic  exercises  are  beneficial,  they  should  never 
be  indulged  in  to  such  an  extent  as  to  tire  out  the 
patient. 

With  reference  to  the  local  treatment  of  the  stom- 
ach,  the  gastric  douche  has  been   recommended   by 

^  Beard  and  Rockwell :  I.  c. 


464  DISEASES   OF   THE    STOMACH. 

Malbranc'  and  lately  by  Eosenheim/  In  a  few  cases 
I  have  applied  the  gastric  spray  with  similar  good 
results.  As  regards  medicaments,  the  bromides  are  of 
the  greatest  importance. 

I^  Ammonii  bromidi, 

Sodii  bromidi, aa  1.0 

M.  f.  pulv.     D.  in  chart.  No.  20.     S.  One  powder  twice  daily 
in  milk  or  in  water. 

The  use  of  the  different  tonics  (iron,  arsenic)  is  fre- 
quently indicated.  Levico  or  Koncegno  water  (one- 
half  to  one  tablespoonful  three  times  daily),  ferratin, 
Gude's  peptomangan,  Dietrich's  peptonate  of  iron  are 
also  in  place.  In  cases  in  which  the  anorexia  plays  a 
dominant  part,  tincture  of  nux  vomica  (ten  drops 
three  times  daily)  or  orexinum  basicum  (2  dgm.  in 
wafers,  three  times  daily)  should  be  administered. 
Insomnia  will  often  have  to  be  remedied  by  the  use  of 
either  chloral  hydrate,  sulphonal  (1|-  to  2  gm.),  or 
trional  (1  to  2  gm.). 

The  bowels  should  be  regulated  according  to  the 
rules  given  in  the  chapter  en  chronic  gastric  catarrh. 
A  sojourn  in  the  mountains  or  in  some  watering-place 
having  mild  ferruginous  springs,  such  as  Elster, 
Franzensbad,  and  Pyrmont,  or  salines  such  as  Ems, 
Wiesbaden,  and  Kissingen,  may  be  recommended, 
while  the  purgative  waters  of  Carlsbad  and  Marien- 
bad  should  be  avoided. 

'  Malbranc  :  I.  c. 

2Th.  Rosenheim:  Therap.  Monatshefte,  1892,  p.  382. 


CHAPTER  XIY. 

THE  CON'DITION   OF    THE    STOMACH    IN    DIS- 
EASES  OF   OTHER    ORGANS. 

There  are  but  few  diseases  which  are  not  attended 
to  a  greater  or  less  extent  with  gastric  symptoms. 
Every  constitutional  or  local  disease,  febrile  and  afe- 
brile processes,  are  all  more  or  less  complicated  with 
disturbances  of  the  digestive  organs.  The  digestive 
symptoms  in  all  these  conditions,  however,  are  de- 
pendent upon  a  general  disturbance  of  the  entire  or- 
ganism and  are  not  due  to  real  affections  of  the  diges- 
tive organs.  They  are  therefore  always  discussed  in 
the  symptomatology  of  the  different  diseases.  In  the 
following  we  shall  briefly  describe  the  condition  of  the 
stomach  in  several  organic  diseases  of  other  organs, 
wherein  the  gastric  symptoms  play  a  predominant 
part.  In  fact,  in  many  cases  it  is  quite  difficult  to 
recognize  the  secondary  nature  of  the  gastric  trouble, 
the  primary  disease  giving  so  few  and  unimportant 
symptoms  that  it  is  easily  overlooked. 

Tuberculosis  of  the  Lungs. — As  is  well  known, 
in  pulmonary  tuberculosis  the  symptoms  of  the  gastro- 
intestinal tract  are  frequently  very  pronounced  and 
very  difficult  to  manage ;  often  there  exist  loss  of  ap- 
petite, disagreeable  sensations  after  meals,  belching, 
bad  taste,  constipation  alternating  with  diarrhoea,  and 
last,  but  not  least,  severe  and  obstinate  gastralgia  as 

30 


4^66  DISEASES   OF   THE   STOMACH. 

well  as  enteralgia.  While  these  gastric  symptoms,  as 
a  rule,  appear  when  the  tuberculous  process  in  the 
lungs  is  already  quite  advanced,  occasionally  they  may 
exist  long  before  there  is  any  evidence  of  a  real  lung 
trouble.  While  the  pathological  anatomy  of  the 
stomach  in  tuberculous  patients  has  been  examined 
by  W.  Fenwick,'  who  found  well-marked  evidence  of 
gastric  catarrh  in  eleven  out  of  fifteen  cases  of  phthi- 
sis, the  functions  of  the  stomach  in  this  affection  have 
been  studied  by  Rosenthal.*  Edinger,^  Klemperer'  and 
Schetty,^  Brieger,*  Hildebrandt,^  Immermann,*  and 
myself.^  My  own  conclusions,  which  harmonize  well 
with  those  of  most  of  the  writers  just  mentioned, 
were  published  in  the  Medical  Record  of  May  4th, 
1889,  and  are  as  follows: 

1.  Among  the  fifteen  cases  of  phthisis  pulmonura 
examined,  free  hydrochloric  acid  was  absent  in  two 
only  (Xos.  14  and  15);  in  a  third  patient  (Xo.  11)  the 
hydrochloric  acid  was  wanting  but  once,  and  was 
present  at  two  other  examinations;  in  all  the  other 
patients  the  hydrochloric  acid  was  always  present. 

2.  As  regards  acidity,  in  five  patients  (Xos.  6  to  10) 
it  was  found  normal ;  five  (Xos.  1  to  5)  showed  hyper- 
acidity; and  five  (Xos.  11  to  15),  a  diminution  in 
the   degree   of   acidity;  among   the  last  group  there 

'W.  Fenwick:  Virchows'  Arch.,  1889,  p.  187. 
SC.  Rosenthal:  Berl.  klin.  Wochenschr.,  1888,  No.  45. 
sEdinger:  Deutsch.  Arch.  f.  klin.  Med.,  1881. 
■*Kleniperer:  Berl.  klin.  Wochenschr.,  1889,  No.  11. 
»F.  Schetty:  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  44,  p.  219. 
*Brieger:  Deutscli.  med.  Wochenschr.,  1888,  No.  14. 
'Hildebrandt:  ibidevi,  1889,   No.  15. 

^Immermann:    Verhandl.    des    Congresses    f.    innere    Medicin 
Wiesbaden,  1889. 

«Max  Einhorn  :  Medical  Record.  Mav  4th,  1889. 


THE   STOMACH   IX   OTHEE   DISEASES.  467 

were  two  with  a  total  absence  of  free   hydrochloric 
acid. 

3.  Only  one  patient  (Xo.  4)  had  in  his  stomach, 
after  the  test  breakfast,  the  remnants  of  the  yolk  of  an 
egg  which  he  had  eaten  on  the  day  previous,  and  that 
but  once.  In  all  other  patients  no  food  whatever  was 
found  in  the  stomach  except  the  fine  pieces  of  the  roll. 
The  stomach  must  have  been  empty  before  taking  the 
breakfast,  and  therefore  it  can  be  concluded  that  the 
motor  power  of  the  stomach  was  not  diminished  in  a 
very  high  degree, 

4.  In  most  cases  a  record  of  the  appetite  was  kept. 
A  priori,  one  would  be  inclined  to  think  that  the  ap- 
petite is  in  a  certain  degree  dependent  upon  the 
amount  of  gastric  juice  secreted.  As  the  amount  of 
gastric  juice  secreted  is  measured  b}'  the  degree  of 
acidity,  the  appetite  ought  to  be  good  where  hyper- 
acidity or  a  normal  amount  of  acidity  exists,  and  bad 
where  there  is  present  a  diminished  degree  of  acidity. 
But  this  is  not  true;  three  patients  with  hyperacidity 
(Xos.  1,  3,  and  i),  and  two  with  normal  acidity  (Xos. 
8  and  10),  complained  of  poor  appetite,  whereas  pa- 
tient Xo.  15  had  a  good  appetite,  although  there  was 
complete  absence  of  free  hydrochloric  acid  in  his 
stomach. 

It  will  be  seen  that  frequently  the  subjective  symp- 
toms do  not  harmonize  with  the  objective  data  found 
in  a  thorough  examination  of  the  stomach.  The  point 
to  be  gained  from  this  fact  with  regard  to  treatment 
is  not  to  be  afraid  of  giving  sufficient  food  to  these 
patients  with  markedly  disturbed  appetite  and  many 
other  dyspeptic  symptoms.     In  fact,  gavage  or  forced 


468  DISEASES   OF   THE   STOMACH. 

alimentation  will  often  prove  very  useful.  Debove, 
Peiper,  Leyden,  and  others  have  obtained  the  most 
beneficial  results  in  phthisical  patients  by  this  method. 

The  treatment  of  the  gastric  symptoms,  in  which 
certain  functional  anomalies  of  the  stomach  (as  for 
instance  hyperchlorhydria  or  hypochlorhydria)  have 
been  found,  will  be  similar  to  that  described  under 
the  head  of  these  latter  conditions.  The  main  treat- 
ment, however,  must  always  be  directed  against  the 
primary  affection,  namely,  the  lung  trouble. 

Tuberculous  ulcers  of  the  stomach  are  occasionally 
met  with,  especially  in  association  with  tuberculous 
lesions  of  other  organs.  Their  occurrence  has  been  de- 
scribed by  several  writers  (Eppinger, '  Litten,'  Musser'). 

In  chlorosis  and  ancemia  the  gastric  symptoms  fre- 
quently play  an  important  part.  They  all,  as  a  rule, 
belong  to  the  neurotic  derangements  of  the  stomach. 
Thus  anorexia,  gastralgia,  hyperaesthesia  of  the  stom- 
ach, atony,  and  hyperchlorhydria  are  frequently  met 
with.  Some  writers  (Hay em  '  and  others)  look  upon 
the  gastric  disturbances  as  the  primary  factor  causing 
the  affection  of  the  blood.  I  concur  with  Ewald  and 
Rosenheim  that  in  the  vast  majority  of  cases  the  di- 
gestive symptoms  are  only  sequelae  and  not  the  pri- 
mary cause  of  the  chlorosis.  The  administration  of 
iron  quickly  improves  the  gastric  symptoms. 

Heart  lesions  are  frequentl}^  attended  with  gastric 
disturbances.  The  latter,  as  a  rule,  are  due  to  hyper- 
semia  of  the  gastric  mucosa  and  consist  in  a  feeling  of 

'  Eppinger :  Prag.  med.  Wochenschr. ,  1881,  Nos.  51  and  52. 
»Litten:  Virch.  Arch.,  Bd.  67,  p.  615. 
sMusser:  Philad.  Hospital  Reports,  1890,  vol.  1,  p.  170. 
^Hayem:  Bull,  medical,  1891,  No.  87. 


THE   STOMACH  IN   OTHER   DISEASES.  469 

pressure  in  the  epigastric  region,  especially  after 
meals,  anorexia,  belching,  etc.  Huefler's'  assertion 
that  there  is  an  absence  of  free  hydrochloric  acid  in 
almost  all  cases  of  valvular  heart  lesions  is  not  correct, 
as  has  been  shown  by  myself  and  later  by  Adler  and 
Stern."  Among  twelve  patients  with  heart  affections 
whose  gastric  contents  I  have  examined,  in  eight  free 
hydrochloric  acid  was  present,  while  in  four  it  was 
absent. 

Gastric  affections  not  infrequently  produce  symp- 
toms simulating  a  heart  lesion.  Thus,  for  instance, 
arhythmia  cordis,  tachycardia,  and  occasionally  brady- 
cardia are  met  with  in  chronic  gastric  catarrh,  in  ner- 
vous disorders,  and  in  atony  of  the  stomach.  Some- 
times it  is  difficult  to  decide  at  first  whether  we  have 
to  deal  with  an  affection  of  the  heart  or  of  the  stom- 
ach, A  thorough  examination  of  the  circulatory  ap- 
paratus and  also  of  the  gastric  functions  will  reveal 
the  true  nature  of  the  disease. 

Like  affections  of  the  heart,  disturbances  of  the  liver 
are  also  almost  always  accompanied  by  gastric  symp- 
toms, due  to  a  hyperaemic  condition  of  the  stomach. 
Thus  in  icterus  and  cirrhosis  of  the  liver  the  stomach 
is  the  first  to  manifest  various  symptoms.  Here,  as 
in  most  other  diseases,  the  secretory  function  of  the 
stomach  does  not  show  any  constancy ;  in  some  cases 
the  gastric  juice  may  be  normal,  in  some  increased, 
while  in  the  greater  number  of  cases  it  is  diminished. 

Diseases  of  the  kidney  are  also  frequently  associ- 
ated with  gastric  symptoms.     Thus  nausea  and  vom- 

^Huefler:  Miinchen.  med.  Wochenschr. ,  1889,  No.  33. 

2  ]yia,x  Einhorn  :  Berl.  klin.  Wochenchr.,  1889,  No.  48. 

3  Adler  und  Stern  :  Berl.  klin.  Wochenschr.,  1889,  No.  49. 


470  DISEASES   OF   THE   STOMACH. 

iting  may  be  the  first  symptoms.  They  are  caused 
either  by  excretion  of  urea  through  the  gastric  mu- 
cous membrane,  or  by  the  retention  of  that  substance 
in  the  circulation  and  the  irritation  caused  thereby 
upon  the  brain.  Biernacki  '  has  made  a  series  of  ex- 
aminations of  the  gastric  condition  in  renal  affections 
and  found  that  in  most  of  them  the  gastric  secretion 
was  greatly  diminished.  Allen  A.  Jones  "  likewise 
frequently  found  achylia  gastrica  among  patients  with 
kidney  troubles.  Stone  in  the  kidney  may  give  rise 
to  similar  gastric  disturbances.  I  have  observed  in  a 
patient  suffering  with  renal  calculus,  achylia  gastrica 
which  had  existed  for  a  long  time,  and  given  rise  to 
many  severe  symptoms.  After  the  removal  of  the 
stone  by  operation  the  gastric  symptoms  at  once  dis- 
appeared. 

The  condition  of  the  stomach  in  diabetes  has  been 
examined  by  Eosenstein  ^  and  Gans.^  The  gastric 
functions  were  found  very  variable.  I  have  had  the 
opportunity  of  examining  quite  a  number  of  diabetics 
with  regard  to  the  gastric  functions  and  must  say  that 
they  do  not  show  any  constancy.  Normal  and  ab- 
normal conditions  of  secretion  are  alike  found. 

In  a  case  of  chronic  m^tliritis  deformans  and  in  two 
patients  with  severe  gout  I  found  achylia  gastrica. 
In  several  instances  in  which  only  slight  symptoms  of 
gout  existed,  I  frequently  found  hyperchlorhydria. 

The  existence  of  gastric   symptoms  in  malaria  is 

'Biernacki:  Berl.  klin.  Wochenschr. ,  1891,  Nos.  25  and  26. 
^ Allen  A.  Jones:    "Gastric  Conditions  in  Renal  Disease,"  New 
York  Medical  Journal,  January  19th,  1895. 

=*  Rosenstein  :  Berl.  klin.  Wochenschr.,  1890,  No.  13. 

^  Edg.  Gans :  IX.  Congress  f .  innere  Medicin,  1890,   Wiesbaden. 


THE   STOMACH   IN   OTHER   DISEASES.  471 

well  known,  and  Leube  '  first  described  several  cases 
of  very  severe  gastralgia  with  absence  of  fever,  which 
were  due  to  malaria,  as  the  successful  treatment  with 
quinine  clearly  proved.  The  malarial  origin  of  the 
gastric  symptoms  will  be  apparent  if  they  are  inter- 
mittent and  appear  only  at  a  certain  time  every  day 
or  every  other  day.  I  have  observed  several  cases  of 
obstinate  vomiting  due  to  malaria,  but  in  most  of 
these  instances  there  have  been,  besides  the  gastric 
symptoms,  other  manifestations  indicating  the  true 
nature  of  the  condition.  The  gastric  secretion  here 
also  does  not  show  any  characteristic  feature,  and  is 
frequently  diminished. 

Diseases  of  the  Skin. — This  subject,  although  of 
particular  interest,  has  as  yet  received  but  very  little 
attention.  Pidoux''  considered  all  cases  of  dyspepsia 
due  to  a  herpetic  state  of  the  system.  The  appearance 
of  eczema,  psoriasis,  pityriasis,  lichen,  or  acne  in  any 
case  he  considered  as  outwg^rd  manifestations  of  that 
constitutional  anomaly  which  he  called  herpetisme. 
Nowadays  no  one  will  be  inclined  to  accept  this  theory 
of  a  general  constitutional  anomaly  for  the  origin  of 
these  troubles  of  the  alimentary  tract.  Notwithstand- 
ing this  there  is  no  doubt  that  occasionally  some  con- 
nection is  found  between  some  skin  manifestations 
and  digestive  disturbances. 

Pemphigus  of  the  mouth  has  been  described  under 
the  name  of  stomatitis  neurotica  chronica  by  A.  Ja- 
c()bi,'of  New  York.     I  observed  this  affection  present 

1  Leube  :  Deutsch.  Arch.  f.  klin.  Medicin,  Bd.  33. 

-Pidoux  :  "Rapport  de  I'herpetisme etdes dyspepsies."  L'Union 
medicale,  1866,  p.  235. 

^  A.  Jacobi :  Transactions  of  the  Association  of  American  Physi- 
cians, 1894. 


472  DISEASES   OF   THE   STOMACH. 

in  three  patients  suffering  from  neurasthenia  gastrica 
and  hyperchlorhydria  respectively.  In  two  of  these 
cases  there  was  an  improvement  of  the  affection  of 
the  mouth  (also  tongue)  in  connection  with  the  abate- 
ment of  the  gastric  symptoms.  In  the  third  case, 
however,  the  pemphigus  resisted  every  kind  of  treat- 
ment and  persisted  even  during  periods  in  which  there 
were  no  complaints  referring  to  digestion.  In  this 
case  there  were  frequently  present  a  burning  sensa- 
tion within  the  oesophagus  and  slight  symptoms  of 
dysphagia.  Most  probably  they  were  also  caused  by 
the  formation  of  vesicular  patches  along  the  oesopha- 
geal wall. 

Urticaria  and  erythema  due  to  absorption  in  the 
digestive  tract  of  some  poisonous  substances  ingested 
with  the  food  (especially  lobsters,  soft-shell  crabs,  fish, 
and  the  like)  are  well  known  and  have  been  referred 
to  above  under  the  head  of  idiosyncrasies. 

With  reference  to  eczema  Hyde'  says:  "No  one, 
however,  can  doubt  for  a  moment  that  many  visceral 
disorders  have  an  influence  upon  the  production  of 
eczema,  repeated  attacks  even  following  accesses  of 
morbid  affections  of  these  organs ;  and  it  is  equally  cer- 
tain that  many  varieties  of  eczema  are  directly  depend- 
ent upon  several  systemic  states  such  as,  most  effective 
in  the  list,  gout  and  rheumatic  gout,  dyspepsia,  con- 
stipation, and  scrofula."  Considering  the  large  num- 
ber of  dyspeptics  which  come  under  my  observation, 
I  must  say  that  the  occurrence  of  eczema  among 
them  is  very  infrequent  indeed.  This  would  rather 
speak  against  an  intimate  connection  between  these 

'  Hyde  :  "  Twentieth  Century  Practice  of  Medicine, "  vol.  v. ,  p.  170. 


THE    STOMACH  IN   OTHER  DISEASES.  473 

two  affections,  although  I  have  seen  a  case  of  eczema 
of  the  scrotum  which  had  resisted  the  most  rational 
methods  of  local  treatment,  in  which  the  skin  trouble 
very  quickly  disappeared  after  amelioration  of  the  gas- 
tric symptoms. 

Acne  simplex  and  acne  rosacea  seem  to  occur  more 
frequently  in  connection  with  affections  of  the  stom- 
ach than  eczema.  Two  patients  of  mine  with  acne 
rosacea  and  chronic  continuous  gastric  succorrhoea 
have  both  shown  a  decided  improvement  of  the  red 
nose  after  an  amelioration  of  the  gastric  symptoms. 
In  one  of  these  patients  I  frequently  noticed  that  the 
skin  affection  became  worse  as  soon  as  there  was  an 
exacerbation  of  the  gastric  symptoms,  but  changed  for 
the  better  upon  improvement  of  the  latter. 

In  some  cases  of  psoriasis,  accompanied  by  digestive 
disorders,  I  did  not  observe  that  the  improvement 
in  the  latter  condition  exerted  any  direct  influence 
upon  the  skin  affection. 


INDEX. 


Abbe,  117 
Abelous,  75 

Abnormalities    in  the  shape  of 
the  stomach,  374 

in  the  size  of  the  stomach,  373 

in  the  position  of  the  stom- 
ach, 874 
Abscess  of  the  stomach,  158 

subphrenic,  216 
Absorptive  function  of  the  stom- 
ach, 84 
Acetic  acid,  test  for,  53 
Achroodextrin,  test  for,  50 
Achylia  gastrica,  324 

definition,  324 

course,  336 

diagnosis,  337 

etiology,  328 

general  remarks,  324 

morbid  anatomy,  327 

prognosis,  337 

symptomatology,  329 

synonyms,  324 

treatment,  337 
Acid,  acetic,  test  for,  52 

hydrochloric,  combined,  es- 
timation of,  54 

hydrochloric,  deficit,   deter- 
mination of,  58 

hydrochloric,    free,    estima- 
tion of,  52 

salts,  estimation  of,  55 
Acidity,  determination  of,  48 
Acids,  volatile,  test  for,  51 
Acne  rosacea,  stomach  in,  473 

simplex,  stomach  in,  473 
Adler,  468 


Aerophagia,  425 

Akoria,  393 

Albu,  367,  371 

Algesimeter,  26 

Allotriophagia,  392 

Alt,  432,  433 

Amylopsin,  69 

Anadenia  ventriculi,  165,  324 

Anaemia,  stomach  in,  468 

Anakinesis,  85 

Anatomy  of  the  stomach,  1 

Anderson,  208 

Angustatio  ventriculi,  374 

Anorexia,  nervous,  394 

Appetite,  definition,  388 

perversion  of,  392 
Armstrong,  237 
Arnold,  264 
Arnott,  126 
Arthritis  deformans,  stomach  in, 

470 
Aspirator,  Boas',  43 
Asthma  dyspepticum,  168 
Atony  of  the  stomach,  453 

definition,  453 

diagnosis,  453 

prognosis,  454 

symptomatology,  453 

synonyms,  453 

treatment,  454 
Atrophy  of  the  stomach,  164,  324 
Auscultatory  percussion,  28 

Baginski,  871 

Bardet's  method  of  direct  electri- 
zation, 141 
Barling,  238 


476 


INDEX. 


Beaumetz,  Dujardin,  367 

Beaumont,  10,  110,  153 

Beard,  137,  463 

Beck,  C,  217 

Bentejao,  451 

Berthold,  188 

Bidder,  11 

Biernacki,  469 

Bile,  action  of,  14 
test  for,  68 

Billroth,  284 

Bird,  278 

Blondlot,  11 

Blood,    condition  of,    in   cancer 
of  the  stomach,  270 
tests  for,  69 

Blood-vessels  of  the  stomach,  3 

Blutin,  126 

Boas,  26,  27,  39,  70,  73,  75,  76, 
78,  132,  133,  269,  278,  279,  288, 
289,  293,  305,  323,  326,  340,  342, 

367,  387,  433,  439,  453,  454,  455 
Boas'  aspirator,  43 

resorcin-sugar  test,  45 
test  for  lactic  acid,  47 

Bocci,  137,  140 

Bouchard,  29 

Bourneville,  431 

Bouveret,     303,     313,     321,    367, 

368,  371,    372,   393,   425,    439, 
452,  460 

Brieger,  17,  466 

Brinton,  165.  187,  196,  205,  217, 
218,    248,    250,    251,    252,    258, 
259,  260,  261,  263,  264,  265,  268 
Brock,   149 
Brunton,  L. ,  15 
Bryant,  249 
Bucket,  stomach,  62 
Bulimia,  390 

cause,  391 

symptomatology,  390 

treatment,  391 
Bull,  117 


Burkhart,  459 
Bush,  126 

Cahn,  277,  448 

Calorie,  98 

Cancer  of  the  stomach,  248 
definition,  248 
diagnosis,  277 
differential  diagnosis,  280 
duration  and  prognosis,  283 
etiology,  248 

hydrochloric  acid  in,  277 
lactic  acid  in,  279 
metastasis,  260 
morbid  anatomy,  254 
palliative  operations  for,  285 
radical  operations  for,  284 
secondary    changes    accom- 
panying, 260 
shape  of  the  stomach  in,  259 
symptomatology,  262 
topographical  relations    of, 

258 
treatment,  284 

Canstatt,  140 

Cantarouo,  431 

Cardia,  cancer  of,  271 
spasm  of,  415 

Cardiospasmus,  415 

Catarrh,  acute  gastric,  151 
chronic  gastric,  163 

Cazenave,  34 

Charcot,  395,  397 

Chewing  the  cud,  429 

Chlorosis,  stomach  in,  468 

Chvostek,  368 

Chyle,  definition,  17 

Chyme,  definition,  13 

determination    of    quantity 
of,  in  stomach,  66 

Cirrhosis  ventriculi,  165 

Clapotage,  29 

Cloquet,  252 

Coley,  254 


INDEX. 


477 


CoHapse  in  ulcer  of  the  stomach, 

233 
Constipation    complicating 

chronic  gastric  catarrh,  184 
Cruveilhier,  187,  205,  224 

Daetttyler,  189 

De  Bary,  75 

Debove',    30,    196,  216,    223,   224, 

251,  313,  468 
Deglutition  sounds,  30 
Dehio,  27 
Dejerine,  407 
Demange,  407 
Descensus  ventriculi,  375 
Devic,  367,  368,  371,  372 
Diabetes,  stomach  in,  470 
Dickinson,  65 
Diet,  97 

in  health,  107 
Dietetics    in   acute    diseases  of 
the  stomach,  113 
in    chronic      affections     of 

the  stomach,  116 
in  diseases  of  the  stomach, 
108 
Digestion,  definition  of,  8 
gastric,  13 
intestinal,  14 
Dilatation  of  the  oesophagus,  416, 

423 
Dimethylamido-azobenzol,  53 
Dittrich,  218 
Dobson,  233 
Douche,  gastric,  132 
Duchenne,  140 
Dyspepsia,  nerTOus,  457 
Dysphagia,  415 

Ebstein,  449 
Eczema,  stomach  in,  472 
Edinger,  466 
Eichhorst,  252 

Einhorn's  method  of  direct  elec- 
trization, 142 


Eisenlohr,  270 
Electricity,  136 

direct  application,  139 
intragastric  application,  139 
percutaneous       application, 
137 
Electrode,  deglutable,  143 

spiral,  150 
Elsberg,  81 
Emmerich,  254 
Enteric  juice,  16 
Enteroptosis,  375 
definition,  375 
diagnosis,  381 
etiology,  377 
general  remarks,  375 
symptomatology,  379 
treatment,  383 
Epigastric  beating,  401 
Eppinger,  468 
Erb,  139,  368 
Erosions  of  the  stomach,  238 

condition  of  the  gastric  juice 

in,  242 
course,  242 
definition,  238 
diagnosis,  245 
etiology,  239 
general  remarks,  238 
symptomatology,  239 
treatment,  246 
Eructation,  424 
Erythema,  stomach  in,  472 
Erythrodextrin,  test  for,  50 
Etat  mamelonne,  163 
Ewald,  C.  A. ,  86,  39,  54,  86,  108 
114,  127,  138,  149,  164,  165,  181 
185,  188,  189,  190,  194,  195,  220 
332,    239,    253,    260,   268.    278 
289,  290,    291,    293,    817,    325 
326,   866,    867,    371,    372,   373 
381,    391,    407,    422,    424,   434 
449,  457,  460,  468 
Ewald,  R.,  888 


478 


INDEX. 


Ewald  and  Sievers'  method  of 

testing  the  motor  function,  85 

Ewald-Boas  expression  method, 

43 
Ewald-Boas'  test  breakfast,  41 
Examination,  methods  of,  18 
physical,  methods  of,  22 
Exploratory  laparotomy,  287 
Expression    method    of    Ewald- 
Boas,  43 

Fen  WICK,  S.,  325 
Fenwick,  W. ,  466 
Ferments,  definition  of,  9 

formed,  9 

unformed,  9 
Fibroma  of  the  stomach,  281 
lleiner.  230,  367,  371 
Fleischer,  46 
Food,  definition  of,  97 

substances,    composition    of 
the  most  common,  99 

utilization  of,  107 
Foods,  animal,  103 

liquid,  106 

vegetable,  105 
Foote,  233,  234 
Forster,   97,  224 
Fox,   Wilson,  194,  224,  251 
Fraukel,  342 
Frerichs,  28 
Friedenwald,  36,  54 
Friedreich,  288 
Fubini,  137 
Fuerstner,  138,  140 

Gans,  470 
Gassuer,  367 
Gastralgia,  404 

diagnosis,  409 

etiology,  406 

symptomatology,  404 

synonyms,  404 

treatment,  413 


Gastrectasia,  373 

Gastric  catarrh,  acute,  151 

Gastric  catarrh,  chronic,  163 

course,  173 

definition,  163 

diagnosis,  173 

differential  diagnosis,  174 

etiology,  166 

pathological  anatomy,  163 

prognosis,  175 

symptomatology,  167 

treatment,  175 
Gastric  contents,  abnormal  con- 
stituents of,  68 

contents,   microscopical    ex- 
amination, 72 

digestion,  13 

douche,  132 

idiosyncrasies,  399 

insufficiency,  453 

juice,  constituents  of,  11 

juice,  physiology  of,  10 

juice,  snail-like  cells  in,  72 

mucosa,  pieces  of,  found  in 
wash  water,  77 

neuroses,  sensorj',  388 

secretion,  different  methods 
of  testing,  60 

spray,  134 

ulcer,    condition  of  the  gas- 
tric contents,  210 
Gastritis  acuta  simplex,  151 

diagnosis,  154 

etiology,  151 

morbid  anatomy,  152 

prognosis,  155 

symptomatology,  153 

treatment,  155 
Gastritis,  acute,  151 

definition,  151 

synonyms,  151 
Gastritis    glandularis  chronica, 

163 
Gastritis  phlegm onosa,  158 


INDEX. 


479 


Gastritis  phlegmonosa,   diagno- 
sis, 159 

morbid  anatomy,  158 

symptomatology,  158 

synonyms,  158 

treatment,  159 
Gastritis,  toxic,  159 

diagnosis,  161 

prognosis,  161 

symptomatology,  160 

treatment,  161 
Gastrodiaphane,  the,  35 
Gastrodiaphany,  34 
Gastro-enterostomy  in  cancer  of 

the  stomach,  286 
Gastrofaradization,  144 
Gastrogalvanization,  145 
Gastrograph,  89 
Gastrokinesograph,  91 
Gastrolith,  281 
Gastroptosis,  375 
Gastroscope,  the,  34 
Gastroscopy,  33 
Gastrostomy   in    cancer    ©f    the 

stomach,  286 
Gastrosuccorrhoea     continua 
chronica,  312 

definition,  312 

diagnosis,  315 

differential  diagnosis,  316 

etiology,  314 

general  remarks,  312 

prognosis,  321 

symptomatology,  314 

treatment,  322 
Gastrosuccorrhoea  continua  peri- 
odica, 304 

definition,  304 

diagnosis,  310 

general  remarks,  305 

prognosis,  310 

symptomatology,  305 

synonyms,  304 

treatment,  310 


Gastroxynsis,  304 

Gerhardt,  238,  239,  367,  371 

Germain  See's  test  meal,  41 

Gerster,  117 

Glands  of  the  stomach,  5 

Glax,  448 

Glenard,     375,     376,     377,    378, 

379,  380,  383,  384 
Glenard 's  disease,  375 
GliicksQiann,  237 
Glusinski,  211,  291 
Goldschmidt,  149 
Goodsir,  77 
Gout,  stomach  in,  470 
Gries,  188 
Griesinger,  249 
Griffini,  189 
Gross,  M.,  133 
Gruber,  97 
Grundzach,  326 
Gull,  395 
Giinzburg's   method    of    testing 

the  gastric  secretion,  61 
phloroglucin  -  vanillin    test, 

45 
Gurgling  sounds,  32 
Gyromele,  150 

Haeberlin,  248,  252,  270 
Haematemesis   in    ulcer   of    the 

stomach,  207 
Haller,  374 
Hampeln,  268 
Hanot,  367 
Harada,  138 
Harttung,  192,  239 
Hauser,  253 
Hay  em,  11,  59,  468 
Hay  em  and  Winter's  method  of 

estimating  hydrochloric  acid, 

57 
Heart  lesions,  stomach  in,  468 
Heartburn,  426 
Heat  unit,  definition  of,  98 


480 


INDEX. 


Hehner,  59 

Hehner  and  Seemann's  method  of 

estimating  hydrochloric  acid, 

56 
Heidenhain,  6 
Heim,  371 
Heinemann,  250 
Heller's  blood  test,  70 
Hemmeter,  96,  131 
Hemmeter-Moritz's    method    of 

examining     the    motor    func- 
tion, 95 
Hemorrhage     in     ulcer    of    the 

stomach,  331 
Henoch,  444 
Henry,  325 
Hepatoptosis,  379 
Herschell's  method  of  testing  the 

absorptive  function,  84 
Heryng,  36 
Hildebrandt,  466 
Hippocrates,  32,  125 
Hirschfeld,  102 
Hoffmann,  97,  138 
Honigmann,  58,  60 
Hubbard,  432 
Ruber's    modification    of    salol 

test,  87 
Huefler,  468 
Hiihnerfeld,  71 
Hunter,  342 
Hyde,  472 

Hydrochloric   acid,     combined, 
estimation  of,  54 
acid   deficit,    determination 

of,  58 
acid,  free,  estimation  of,  52 
acid,  tests  for,  44 
Hypauakinesis  ventriculi,  445 
Hyperacidity,  291 
Hypereesthesia  of  the  stomach, 
401 
diagnosis,  402 
symptomatology,  402 


Hyperaesthesia  of  the  stomach, 

treatment,  403 
Hyperanakinesis  ventriculi,  446 
Hj'perchlorhydria,  291 

course,  296 

definition,  291 

diagnosis,  298 

differential  diagnosis,  299 

etiology,  293 

general  remarks,  291 

prognosis,  298 

symptomatology,  294 

synonyms,  291 

treatment,  300 
Hypersecretion,  291 
Hypochlorhydria,  457 

Idiosyncrasies,  gastric,  399 
Immermann,  466 
Incontinence  of  the  pylorus,  449 
Inflation  of  the  stomach,  28 
Ingesta,  examination  of,  44 

hydrochloric  acid,  44 

reaction,  44 
Inspection,  22 
InsuflSciency,  gastric,  453 
Interrogation  of  the  patient,  18 
Intestinal  digestion,  14 

juice,  test  for,  68 
Ischochymia,  340 

acute,  342 

chronic,  344 

complications,  366 

constant,  344 

course,  345 

definition,  340 

diagnosis,  360 

differential  diagnosis,  361 

etiology,  345 

general  remarks,  340 

symptomatology,  342 

transient,  343 

treatment,  362 
Israel,  382 


INDEX. 


481 


Jacobi,  a.,  471 

Jacobson,  36,  372 

Jaworski,  73,  183,  194,  211,  291, 

326 
Johannessen,  430,  431,  436 
Jones,  Allen  A.,  149,  326,  470 
Juergensen,  433.  436 
Juice,  enteric,  16 

gastric,  see  Gastric  juice 
intestinal,  test  for,  68 

Kahler,  407 

Kamraerer,  F. ,  357 

Katzenellenbogen,  259,  263 

Kaufmann,  75,  76 

KeUing,  363 

Key,  193 

Kidney,  movable,  882 

stomach  in  diseases  of,  469 
Kinnicutt,  325 
Kirkpatrick,  237 
Klemperer,  270,  279,  466 
KQemperer's  oil  test,  88 

test  meal,  41 
Koch,  190 
Koenig,  122 
Koerner,  431,  436 
Korczynski,  194 

and  Jaworski 's  blood  test,  71 
Kroneckei',  30 
Kulneff,  371 
Kupffer,  6 
Kussmaul,  126,  139,  366,  367.  370, 

447 
Kussinaul's     method    of    direct 

electrization,  140 
Kuttner,  36 

Laache,  270 

Lactic  acid,  estimation  of,  52 

acid,  test  for,  46 
Laker,  33 
Landau,  375 
Landerer,  237 
31 


Landouzy,  407 

Lange,  F.,  117,  353,  359 

Langerhans,  193,  239 

Latent  ulcer  of  the  stomach,  211 

Lauenstein,  237 

Lavage,  126 

contraindications  for,  132 
Friedlieb's  apparatus,  129 
funnel  arrangement  for,  126 
indications  for,  132 
Leube-Rosenthal   apparatus, 

127 
rules  for  its  application,  131 
with  tube  d  double  courant, 
131 
Lebert,  152,  248,  250,  252,  259,  260 
Lente,  138 
Leo,  391 
Leo's  method  of  estimating  acid 

salts,  55 
Leube,  88,  108,  110,  138,  181,  224, 

228,  375,  457,  470 
Leube-Riegel's  test  dinner,  40 
Leube's  method    of  testing  the 

motor  function,  85 
Leubuscher,  138,  321 
Leven,  367,  459 
Lewy,  325 

Ley  den,  407,  440,  468 
Lipoma  of  the  stomach,  381 
Litten,  326,  468 
Liver,  function  of,  15 

stomach  in  diseases  of,  469 
Loeb,  371 
Loven,  8 
Ludwig,  137 
Luettke,  59 
Lugol's  solution,  50 
Lymphatics  of  the  stomach,  7 

Macfadyen,  75 
Malacia,  392 
Malaria,  stomach  in,  470 
Malbranc,  132,  464 


482 


INDEX. 


Maltose,  test  for,  50 

Manges,  36 

Marcet,  190 

Markoe,  236 

Marti  US:  36,  59,  314 

Mathieu,  67,  251 

McBuruey,  117 

McCosh,  237 

Mechanical  function,  89 

Megastria,  373 

Metena,  208 

Meltzer,  30 

Meltzing,  36 

Menetrier,  253 

Mering,  von,  277 

Merycisni,  429 

Methods  of  examination,  18 

of  physical  examination,  22 
Meyer,  George,  325 
Meyer,  Willy,  117,  354,  355 
Microscopical     examination     of 

gastric  contents,  72 
Mikulicz,  34 
Miller,  75 
Milliot,  34 
Minkowski,  77 
Mintzs    method   of    estimating 

free  hydrochloric  acid,  53 
Mitchell,  Weir,  124,  397 
Moerner    and    Boas'   method  of 

estimating  free    hydrochloric 

acid.  53 
Moritz,  96 
Motor  function,  85 
Mucus,  test  for,  68 
Miiller,  F.,  270,  367,  371 
Munk,  98 
Murphy,  117 
Musser,  468 

Myasthenia  ventriculi,  453 
Myoma  of  the  stomach,  281 

Nausea,  401 
Neftel,  138 


Nencki,  75 
Nephroptosis,  379 
Nerves  of  the  stomach,  7 
Nervous  affections  of  the  stom- 
ach, 386 
Nervous  anorexia,  394 

diagnosis,  396 

symptomatology,  394 

treatment,  396 
Nervous  dyspepsia,  457 

definition,  457 

diagnosis,  461 

differential  diagnosis,  461 

etiology,  458 

prognosis,  460 

symptomatology,  458 

treatment,  462 
Nervous  vomiting,  437 

diagnosis,  461 

idiopathic,  443 

juvenile,  439 

periodic,  440 

reflex,  442 
Neumau,  366 

Neurasthenia  gastrica,  457 
Neuroses,  motor,  414 

secretory,  455 

sensory  gastric,  388 
Nolte,  188,  201 
Noorden,   von,    58,    60,   99,   108, 

119,  407 
Nothnagel,  325 
Nussbaum,  6 
Nutritive  enema,  114 

(Edema  fugax  in  cancer  of  the 

stomach,  269 
CEsophagus,    dilatation  of,   416, 
423 
retention  of  food  in,  274 
Oil  test,  Klemperer's,  88 
Oka.  138 

Oppenchowski,  417 
Oppenheim,  407 


INDEX. 


483 


Oser,  152,  284,  407 
Osier,  23,  325 

Pacaxowski,  458 

Paliard,  371 

Palpation,  24 

Pancreatic  secretion,  16 

Panum,  193 

Pariser,  36 

Park,  Eoswell,  117 

Parker,  237 

Parorexia,  353 

Patient,  interrogation  of,  18 

Pavy,  194 

Peiper,  468 

Pemphigus  of  the  month,  stom- 
ach in,  471 

Penzoldt,  27,  102,  104,  111 

Penzoldt-Faber's  method  of  test- 
ing the  absorptive  function.  84 

Pepper,  W.,  29,  139 

Pepsin,  test  for,  49 

Peptone,  test  for,  49 

Peptonuria  in  cancer,  271 

Percussion,  26 

auscultatory,  28 

Percy,  393 

Perforation  in  ulcer  of  the  stom- 
ach, 232 

Peristaltic    restlessness     of     the 
stomach,  446 

Pettenkofer,  97 

Peyer,  391 

Pfuhl,  217 

Phenolphthalein,  48 

Phloroglucin-vanillin  test,  45 

Phthisis  ventriculi,  324 

Physiology  of  the  stomach,  8 

Pica,  392 

Pidoux,  471 

Piorry,  26 

Pneumatosis,  444 

Polyphagia,  393 

Ponsgen,  437 


Prochoresis,  85 

Propeptone,  test  for,  49 

Prout,  10 

Psoriasis,  stomach  in,  473 

Ptyalin,  definition,  10 

Pus,  recognition  of,  72 

Pylorospasmus,  451 

Pylorus,  cancer  of,  276 
benign  stenosis  of,  349 
incontinence  of,  449 
malignant  stenosis  of,  355 

Pyopneumothorax  subphrenicus, 
216 

Pyrosis,  426 

Quincke,  189 

Rate,  149 

Reaumur,  10 

Regurgitation,  427 

Reichmann,     36,    291,    304,    805, 

312,  313,  314,  317,  322,  323 
Remond,    30,    67,    196,    216,   228, 

224,  318 
Rennet  ferment,  test  for,  50 

zymogen,  test  for,  50 
Ren  vers,  86,  867,  409 
Resorcin-sugar  test  of  Boas,  45 
Respiratory  sounds,  32 
Restlessness,    antiperistaltic,    of 
the  stomach,  448 
peristaltic,    of  the  stomach, 
446 
Richet,  456 
Richter,  138,  460 
Riegel,    194,    210,  291,  318,   314, 

822 
Rindfleisch,  193 
Ringing  sounds,  33 
Rockwell,  137,  453 
Roentgen  rays,  38 
Rokitansky,  193 
Rose,  A.,  29 
Rosenbach,  81,  840,  453 


484 


INDEX. 


Rosenheim,  59,  60,  i;«.  133.  149, 
196,  219,  230.  253,  280,  289.  326, 
363,  402,  403,  404,  464,  468 
Rosenstein,  470 

Rosenthal,  388.  392,  393.  394,  395 
Rosenthal,  C.  466 
Rossbach,  304,  305 
Rumination,  429 

chemical  analysis,  431 

definition,  429 

duration,  431 

etiology,  429 

synonyms,  429 

treatment,  436 
Runebeig,  28 

Sachs,  6,  153 
Sahli,  61 

Saliva,  definition,  10 
Salol  test.  86,  87 
Sarcinte  ventriculi,  77 
Schaeffer,  321 
Schetty,  466 
Scheuerlen,  254 
Schillbach,  137 
Schlesinger,  371 
Schmidt,  11 
Schneider,  270 
Schneyer,  270 

Schonbein-Almen's  blood  test,  Tl 
Schreiber,  314 
Schutz,  448 
Schwann,  11 
Sclerosis  ventriculi,  165 
Secretory  function  of  the  stom- 
ach, 39 
neuroses,  455 
See,  Germain,  371 
Seemann,  59 
Seglas,  431 
Semmola,  138 
Senn,  117 

Sensations,  abnormal,  400 
Sere.  L    de,449 


Silbermann,  190 

Simmons,  351 

Singultus,  425 

Sitieirgy.  395 

Sitophobia,  402 

Sizzling  sounds,  33 

Sjcequist,  54.  59 

Skin,  stomach  in  diseases  of,  471 

Snail-like  cells  in  gastric  juice, 

72 
Snow,  252 
Sohlern,  von,  188 
Sollier,  395 
Sommerville,  126 
Sounds  of  the  stomach,  29 
Spallanzani,  10 

Spallanzani  and  Edinger's  sponge 
method  of  testing   the  gastric 
secretion,  61 
Spasm  of  the  cardia,  415 
diagnosis,  422 
prognosis,  423 
symptomatology   415 
treatment,  423 
Spectroscopic  test  for  blood,  70 
Splanchnoptosis,  379 
Splashing  sound,  29 
Spray,  gastric,  134 
Starch  digestion,  products  of,  50 
Steapsin,  69 

Stenosis  of  the  pylorus,  benign, 
349 
malignant,  355 
Stern,  469 

Stewart,  D.  D.,  36,  149,  327 
Stiller,  439 
Stinison,  237 

Stockton,  36,  148,  149,  194,  456 
Stockton's  stomach  electrode,  142 
Stoehr,  6 

Stomach,    abnormalities    in  the 
position  of,  374 
abnormalities    in  the   shape 
of,  374 


INDEX. 


485 


Stomach,  abnormalities  in  the 
size  of,  373 

abscess  of,  158 

absorptive  function  of,  84 

anatomy  of,  1 

antiperistaltic  restlessness 
of,  448 

atony  of,  453 

atrophy  of,  164,  324 

blood-vessels  of,  3,  7 

bucket,  63 

cancer  of,  248 

condition  of,  in  other  dis- 
eases, 467 

dilated,  373 

electrode,  deglutable,  143 

erosions  of  the,  238 

examination  in  the  fasting 
condition,  88 

glands  of,  5 

hour-glass  form,  374 

hypertesthesia  of,  401 

in  ansemia,  468 

in  arthritis  deformans,  470 

in  chlorosis,  468 

in  diabetes,  470 

in  diseases  of  the  kidney,  469 

in  diseases  of  the  liver,  469 

in  diseases  of  the  skin,  471 

in  gout,  470 

in  heart  lesions,  468 

in  malaria,  470 

in  pulmonary  tuberculosis, 
465 

local  treatment  of,  126 

lymphatics  of,  7 

mechanical  function  of,  89 

methods  of  inflation,  28 

motor  function  of,  85 

mucous  membrane  of,  4 

muscular  coat  of,  4 

nerves  of,  7 

nervous  affections  of,  386 

peristaltic  restlessness  of,  446 


Stomach,  physiology  of,  8 

relations  to  neighboring  or- 
gans, 3 
secretory  function  of,  39 
situation  of,  2 
sounds  of,  29 
structure  of,  3 
submucous  coat,  4 
transillumination  of,  34 
transposition  of,  374 
tube,  contraindications  to  its 

use,  60 
ulcer  of  the,  187 
vertical  position  of,  375 

Strauss,  59,  60,  363 

Structure  of  the  stomach,  3 

Subphrenic  abscess,  216 

Succussion  sound,  32 

Talma,  400 

Teichmann's  hsemin  test,  71 

Test    breakfast    of  Ewald-Boas, 
41 
dinner  of  Leube-Riegel,  40 
meal  of  Germain  See,  41 
meal  of  Klemperer,  41 

Tests  for  hydrochloric  acid,  44 

Tetany,  366 

etiology,  370 
prognosis,  368 
symptoms,  368 

Thayer,  280 

Thompson,  W.  Gilman,  115 

Toepfer,  54 

Toepfer's  method  of  estimating 
free  hydrochloric  acid,  53 

Tongue,  inspection  of,  23 

Transillumination  of  the    stom- 
ach, 34 

Trousseau,  287,  367,  368 

Trypsin,  69 

Tschelzoff,  183 

Tuberculosis,   pulmonary,   stom- 
ach in,  465 


486 


INDEX. 


Tumor,  particles  of,  83 
Turck,  150 

Uffelmann,  46,  98 
Uflfelmann's  lactic-acid  test,  46 
Ulcer  of  the  stomach,  187 

complications,  213 

definition,  187 

diagnosis,  219 

differential  diagnosis,  320 

duration,  212 

etiology,  187 

latent,  211 

localization,  222 

morbid  anatomy,  195 

multiple,  201 

perforation,  213 

prognosis,  223 

progress,  201 

situation,  196 

surgical  treatment,  233 

symptomatology,  203 

synonyms,  187 

treatment,  224 
Unverricht,  365 

Urine,  condition  of,  in  cancer  of 
the  stomach,  270 


Urticaria,  stomach  in,  472 

Van  den  Velden,  277 

Vassale,  189 

Vierordt,  102 

Virchow,     97,     193,     239,     2481 

375 
Voinovitch,  321 
Voit,  97 

Volatile  acids,  test  for,  51 
Vomiting,  nervous,  437 

Waldeyer,  254 

Weber,  70,  137 

Wegele,  150 

Weir,  117,  233,  235,  236,  237 

Welch,  201,  250,  251,  259 

Wiederhoefer,  251 

Wilkinson,  251 

Willigk,  248 

Winter,  11,  59 

Witzel,  286 

Wolff,  322,  326 

Wyss,  248 

ZlEMSSEN,    von,    137,     142,    224, 
228 


i^ 


COLUMBIA  UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

1 

C28(63B)MS0 

RC816  Ei6 

1898 
Einhom 


